Transparency in Outcomes
College calls for protection and development of more specific functional measures and specialized services
The Government launched a full consultation and engagement process on how the NHS Outcomes Framework should be developed. The purpose of this consultation was to seek the help of those working in the NHS, patients and the public in developing this NHS Outcomes Framework.
The College agrees in principle to the proposed outcomes framework
However, the College highlights the need to recognize person-centred care and develop more indicators that are functional as well as condition specific. These could include e.g. measures of mobility and activities of daily living.
It will be essential to ensure the protection and development of specialised services such as those for people with complex physical disabilities, learning disablities or children, where the relative numbers of people requiring these services is low, but the needs are high
Reablement and rehabilitation requires that clients with these needs have access to health and social care professionals with the necessary specialised expertise, skills and knowlege, as well as provision and maintenance of essential equipment, such as specialised seating, wheelchairs and enviromental controls systems.
As more Quality Standards are developed it will be necessary to consider various cross-cutting themes e.g. transition from children’s to adult services, quality of life, self care and access to employment. The outcomes framework can help to shift the focus of NHS management away from measuring targets to providing better health outcomes for patients.
Download the College’s response to Transparency in Outcomes
Overview of the College's consulation response to Transparency in Outcomes
The Transparency in Outcomes framework focuses on measuring quality of care, where quality is defined as effectiveness of intervention, patient safety and patient experience. The focus is on outcomes rather than structures (how care is delivered), or processes. The aim is to focus on and measure what actually happens to patients and service users. The framework is divided into 5 outcome domains:
- preventing people from dying prematurely
- enhancing the quality of life for people with long term conditions
- helping people to recover from episodes of ill health or following injury
- ensuring people have a positive experience of care
- treating and caring for people in a safe environment and protecting them from avoidable harm.
It is anticipated that of the domains will have an overarching outcome indicator, 5 more specific improvement areas and a number of supporting NICE Quality Standards. There is also an aim to develop, improve and use Patient Related Outcome Measures (PROMs)
In responding to the consultation for the framework, The College of Occupational Therapists made a number of comments and recommendations. A selection of these are outlined below.
Outcome measures - selection of measures and data collection
Additional data collection by front-line staff will impact on sustainablility of services, in terms of the time and resources needed to collect the data. The potential costs of data collection and recording should not be ignored. However, these costs could be partly off-set by stopping the routine collection of process data, e.g. on staff activity and some performance targets, that have not been shown to improve the overall health status of the population, either locally or nationally.
Many front-line clinical staff and their immediate managers are still frustrated by the slow pace of development of comprehensive electronic care record systems. These IT systems are essential to support NHS staff who are trying to provide specialist care within a complex health and social care system.
The fact that some indicators are functional as well as condition specific is welcome (e.g Domain 2 over-arching indicators). This will help facilitate a more coordinated approach and improve equality, since outcomes for patients with a wider variety of conditions are included. More specific functional measures, which include mobility, activities of daily living etc would also be useful.
There is an assumption that existing outcome measures are robust and measure what they say they measure, which is not entirely true. There is a need for a strategic approach to develop a new generation of outcome measures that will improve clinician's ability to measure the outcomes for their patients.
Additionally, if we focus on measures which can be measured from April 2011, There is a danger that the focus will remain on what is relatively easy to measure, rather than developing indicators for areas where measurement is limited at present. An example might be outcomes for elderly patients who are admitted to acute services and discharged to community.
It must be recognised that measures used to evaluate outcomes in hospital may not be suitable for evaluating outcomes in other health, public health and social care arenas. Outcomes should be relevant to the needs of individuals, who may have multiple needs or problems.
It is worth considering indicators that reflect older people's ability to live independently at home. This could provide a useful link to social care.
Domain 3 - Helping people to recover from episodes of ill health
The aim should be to minimise all admissions and readmissions for 'all acute conditions usually managed in primary care'. (i.e. rather than focusing on emergency care).This might encourage hospital doctors and GPs to have a more effective dialogue and minimise unnecessary admissions. This is particularly relevant for patients with fluctuating conditions such as multiple sclerosis.
It is particularly important to understand the underlying, contextual, and precipitating reasons for unplanned care. Services should elicit responses from patients or their carers, to identify ideas for changes that could have helped services to prevent the episode of unplanned care. Services can then be improved as necessary. This could include patient questionnaires, or questionnaires for carers, families or friends to complete if the service user is unable to complete a questionnaire. Depending on the circumstances, items could be selected from: appropriateness of discharge plans or care plans, follow-up services, availability of information, or condition specific items such as the effectiveness of prevention strategies (falls, diabetes, thyroid, parkinsons, dementia support).
Domain 4 - experience of care
The development process should seek to elicit information on patients' more personal experiences of care e.g. feeling understood by staff, that care has been individual to their personal needs and not be limited to experiences that are more tangible/confined to the physical environment, such as cleanliness of the environment, access to toilets, etc.
General comments
Domains 1 and 2 will need careful thought to ensure that the NHS considers optimising patients' quality of life alongside efforts to prolong their lives. The outcomes framework and commissioning arrangements need to reflect that many patients do not separate their health needs from their social care needs. Effective partnership is essential to ensure health and social care organisations collaborate to reduce inequalities.
It is our understanding that an outcomes framework for public health is currently being developed. This needs to address the reasons for health inequalities, including inequalities in income, housing, employment, or as a result of disability. It is only by addressing these issues that more equitable health outcomes can be achieved. The NHS Outcomes Framework must link directly with public health if it is to deliver more equitable outcomes.
It will be essential to ensure the protection and development of specialised services such as those for people with complex physical disabilities, learning disablities or children, where the relative numbers of people requiring these services is low, but the needs are high. Reablement and rehabilitation requires that clients with these needs have access to health and social care professionals with the necessary specialised expertise, skills and knowlege, as well as provision and maintenance of essential equipment, such as specialised seating, wheelchairs and enviromental controls systems.
It is also important that people with rare and/or progressive conditions are included in the framework, even where the outcome measures are likely to get worse, due to the deterioriating nature of the condition.
There is an urgent need to improve access for care professionals to all relevant information about their individual patients / clients, whether it was recorded in NHS or social care information systems. Shared patient information is a pre-requisite for fully integrated health and social care services.
It is essential that resources and funding for both health and social care are adequate. We look forward to proposals to ensure long term funding and sustainability for social care being published in 2012. It may be useful to draw upon the experience of health and social care professionals who are already working across organisations, delivering integrated services, such as occupational therapists.
There needs to be agreed defintions of 'health' and 'quality of life'. For occupational therapists these concepts are related to enabling patients to function optimally at work, at home, at school, socially and in the community.
Implementation of the outcomes framework may require a shift in focus in some clinical teams, particularly in acute wards that may focus on numbers and throughput, and not on personalised care or preventing readmission. For example, patients with dementia need their acute physical care needs to be carefully explained, which takes time and a personalised approach.
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