Feature / A measure of success

Finance practitioners will by now be familiar with the growing calls for value-based decision-making in the NHS. The basic thrust is that looking simply at outcomes or costs in isolation will lead to imperfect decisions – you need to look at both in parallel. But while the NHS has a plan to deliver improved cost data based on a consistent methodology, there has been no similar nationally co-ordinated approach to outcome measurement.

Not-for-profit organisation the International Consortium for Health Outcomes Measurement (ICHOM) has made it its mission to fill this gap, not just for the NHS but for health systems across the globe. By 2017, in just two years’ time, it aims to have published 50 standard sets – setting out agreed outcome measures and how to measure them – covering more than 50% of the global disease burden.

This sounds ambitious, but the body is also convinced that in the course of this Parliament, all NHS providers can have implemented at least one standard set and be on course for adopting them all.

The organisation and its mission is perhaps the natural result of the whole healthcare value movement started by Professor Michael Porter in the mid 2000s. This effectively called on healthcare systems to change their culture and target the delivery of value – the best outcomes for the lowest cost.

It sounds an obvious goal, but it dragged attention towards measuring value in terms of actual outcomes and away from a simplistic consideration of the volume of services delivered. It also underlined the danger of looking to simply contain or reduce cost without a clear understanding of the real impact on outcomes.

Professor Porter argued that outcomes must reflect what matters most to patients and can be broken into different types of outcome, including health status, process of recovery and sustainability of health. These needed to be identified medical condition by medical condition and that is exactly what ICHOM is aiming to do. ‘The key starting point is to measure the right outcomes,’ says Jason Arora, a doctor and project leader at the standards body. ‘They need to be globally standardised, in the same format and, importantly, be the outcomes that matter most to patients.’

Crucially, the body thinks there is little point in every single health provider separately identifying which outcome measures to use for each condition. This would clearly mean significant duplication of effort, but it might also lead to outcome measures that were not comparable between providers and across health systems, reducing their value as a benchmarking and improvement tool.

The organisation has worked with patients, academics and clinicians – experts in the relevant medical conditions – to start putting the standard sets in place. Twelve sets are already available, seven are being developed and many more are being considered.

Global outcomes

Standards development is just the first step. ‘Once they are developed, we need to drive implementation and shift hospitals and registries from what they are currently measuring, if anything, to a globally agreed set of outcomes,’ says Dr Arora. ‘Once we have the global community measuring the same outcomes, you can really start to compare and benchmark, identify best practice, analyse the processes and then standardise and raise the quality of care by reducing unnecessary and costly events, such as complications and re-interventions. That will also enable you to look at the cost of achieving key outcomes and which costs don’t contribute to the outcomes wanted by patients. Ultimately you can start to contract and commission for true value.’

With some standards already published and more under way, increasing numbers of organisations are implementing standard sets. Many are outside the UK, but there are a significant number of NHS pioneers. The Aneurin Bevan University Health Board is implementing the Parkinson’s disease standard set, while a group of hospitals (Imperial, Royal Free, West Suffolk and Milton Keynes) is working to implement the cataract set.

Clinical commissioning groups are also supporting adoption (in Camden and in Bedfordshire). And at national levels, NHS England and the Scottish government are supporting development work for standard sets covering older people and dementia respectively. In total across the world, ICHOM says ‘at least’ 60 organisations are already measuring outcomes using their standards.

There are even some early moves to start comparison work. ‘We have 10 institutions over four continents measuring cleft lip and palate outcomes according to our standard set this year,’ says Dr Arora.

‘We are facilitating this process to ensure the set is implemented in its entirety and that the outcomes collected are in a uniform format. We hope to benchmark these outcomes in 2017 so we can compare approaches and results.’

But even if organisations recognise the value of measuring outcomes, is it the right time – in the middle of a significant financial challenge – to expect them to launch major new initiatives with clear resource implications? ‘In our experience, the financial challenge is not always a problem,’ says Tom Kelley, a medic and Europe director at ICHOM. ‘When we identify a board and clinicians that are bought into the concept, they often find ways to make the investment,’ he says. ‘And that is happening all over the world.’

Investment support

Dr Kelley also insists that lack of resources to invest is a red herring. ‘Investment is required, but it is not as difficult as it might seem because efficient, systematic measurement of outcomes can often be done in a very cost-effective, affordable way,’ he says.

For a start, ICHOM is providing support to help organisations implement standard sets. But even without that, he insists, it does not take long to start realising benefits. ‘It is vital for any organisation to know their results, because if you don’t it is impossible to improve,’ he says. ‘There is good evidence that high-quality care is cheaper, in both the short and longer term. So this is definitely a way to help save costs. But we need to be defining high-quality care from the perspective of the people receiving the care.’

He says ‘different organisations will be at different stages in their readiness’ to adopt the standards, so organisations shouldn’t be forced to adopt. It is about ‘opening up’, recognising there are things you could do better, understanding what those things are and targeting them. And that won’t work unless organisations are committed to the process.

Dr Kelley is keen to underline that ICHOM is defining core outcomes that ‘reliably apply in different parts of the world’ – not a comprehensive list of all potentially relevant indicators. ‘There will be other outcomes that are important in particular regions, so there has to be space to allow for that variation.’

Having made the case for flexibility, Dr Kelley says it is possible to identify the ‘core’ outcomes – outcome standards that most people want with a particular condition. People with prostate cancer do not want to be incontinent, for example, and the key becomes ensuring it is measured in the same way, so that results are comparable. He is ambitious about getting health bodies to sign up voluntarily. ‘In the NHS, we should have all health economies in England, Scotland, Wales and Northern Ireland systematically measuring outcomes that matter to patients,’ he says. ‘This should include a standardised component, but allow for populations to add in outcomes that are important locally. This is very achievable.

We should at least have all organisations on track to achieve these standards in this Parliament.’

He hopes that within the next five years the promised standard sets will be published and all NHS providers will be measuring at least one set and on track to adopt the others.

Professor Porter and his Harvard Business School colleague Robert Kaplan have talked about a final stage in the value process – linking outcomes to payment. Dr Kelley agrees. ‘It is important we can contract for outcomes and commission providers to deliver services and measure outcomes and costs,’ he says.

He agrees the NHS should move away from purely volume-based payment for services. ‘However, as we move to link outcomes with payment, we have to also ensure that value measurement increases collaboration between different providers – locally, nationally and internationally,’ he says. ‘This is vital if we are to truly increase the quality of services for patients and their families.’