It’s time to take outcomes-based commissioning out of the ‘too difficult’ box | Dr Rupert Dunbar-Rees

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Refocusing healthcare on delivering outcomes and value is now part of the zeitgeist. It is even becoming part of the reality in the NHS – in a recent Health Service Journal poll (March 2014), 64 per cent of clinical commissioning groups (CCGs) reported they are planning to re-contract a significant amount of services under outcomes-based contracts in the next year.

The intellectual premise and evidence – stemming mostly from Porter, Teisberg and Lee’s seminal work on value – is largely accepted. Yet the truth is that, beyond the rhetoric, outcomes-based commissioning still sits in the ‘just too difficult’ box for many.

“What are we trying to achieve? A new focus on outcomes for patients and value for taxpayers”  Simon Stevens, chief executive, NHS England, June 2014.

There is no substitute for measuring actual outcomes, whose principal purpose is not comparing providers but enabling innovations in care.”  Professor Michael E. Porter, What is value in healthcare?.

Outcomes are the results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives.International Consortium for Health Outcomes Measurement (ICHOM).

“Measuring care and outcomes in mental health is often put in the ‘too difficult’ box yet capturing data on whether people have homes to live in, jobs to go to, appropriate medication, financial stability and social interactions are possible for other conditions so why not for people with mental health problems too.” The case For change for British mental health care, Dr Emma Stanton, JRSM.

Having worked with trusts, CCGs, clinicians and people with a variety of health conditions and needs across the UK for some time now, we at Outcomes Based Healthcare (OBH) have noticed that the same concerns (excuses?) and perceived challenges keep cropping up. In response, we recently launched the #outcomesmyths campaign, busting a myth a week about implementing outcomes-based change, and inviting people to share their experiences. 

In pulling this campaign together, we spoke to experts from across the field (and across the pond), gathering insights, experiences and resources to help others working on making outcomes-based commissioning a reality, and to debunk common misconceptions. 

In the process, we’ve tackled the myths that outcomes are too difficult to define, measure and contract for, and the claim that there are just too many cultural barriers. You can find the exploded myths in full on our website, but for now, here are a few of our tips and lessons: 

  1. Seek out the early adopters, champions and hidden value enthusiasts, especially among clinicians – this is a radical change, and every part of the health and care system needs to be involved, so you need people to help drive this forward and get others on board with the shared vision.
  2. Identify and listen to people who share similar health needs – you can trust them to define the outcomes that matter most to them. That said, there is a real skill to devising meaningful and measurable outcomes – it does not mean taking what people say they want at face value.
  3. Be pragmatic, especially when it comes to looking at the data you need to measure those outcomes. Our experience suggests that, for a typical patient segment, data exists which allows 50 to 60 per cent of outcomes to be measured – and this may be a good enough start. The rest may require additional data collection, often asking people to report back on their outcomes.
  4. ‘Engage, engage again and then do some more engagement’ – a clear message from more than one of the people we’ve spoken to. You need to keep on making the case, but you also need to listen and respond to the real practical and financial concerns that will crop up, particularly among providers facing a change to the traditional contracting model.
Finally, there is real devil in the detail, not least when it comes to exploring different approaches to contracting. That is why we have been working with Capsticks on behalf of north central London CCGs to produce a detailed analysis of the options for contracting for outcomes in the NHS, launching this week. 

Dr Rupert Dunbar-Rees is a GP by background and founder of Outcomes Based Healthcare. Follow him on Twitter @rupsdr 

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