Feature / Outcome and expenditure

The NHS will begin collecting patient outcomes for a limited number of acute procedures from 2008/09 but the Office of Health Economics believes it could be done more widely and quickly. OHE deputy director Jon Sussex reports

The purpose of the NHS is to improve the health of the UK population. To do that it receives well over £100bn of taxpayers’ money per year – an amount that has been growing at 10% a year. It employs 1.5 million people in the UK and uses billions of pounds of capital assets. Costing methodologies are improving – giving us an ever clearer picture of what it costs to deliver different kinds of healthcare to different groups of patients – yet we still know remarkably little about how much our health is being improved as a result of the massive expenditure and effort in the NHS. 

Routine measurement and analysis of the outcomes of healthcare for patients is required. The accountability of the NHS and the ability to manage its effectiveness and efficiency depend on knowing the outcomes achieved for its patients. The recently published report of the Office of Health Economics (OHE) commission, NHS outcomes, performance and productivity (below), demonstrates that this is a practical proposition across a wide range of health services.

The Department of Health has made a welcome start in England by including in its Operating framework for the NHS in England 2008/09 a requirement for NHS providers to collect patient-reported outcome measures for elective primary hip and knee replacements, groin hernia surgery and varicose vein procedures. But the OHE commission report goes much further.

The OHE established the Commission on NHS Outcomes, Performance and Productivity in autumn 2006. Chaired by Professor Peter Smith, director of the University of York Centre for Health Economics, the commission’s members are experts from clinical, managerial, patient and economist perspectives. Its purpose was to review the evidence and determine what patient outcomes data could and should be collected and analysed routinely in the NHS.

Three-level approach
Data on patient outcomes is needed to answer three levels of questions (see figure). First, providers of healthcare, the NHS staff who deliver that care and the commissioners of care all need information on outcomes to benchmark and improve the effectiveness and quality of their care. Patients also require performance measures to enable them to compare providers. At a second level, commissioners of care – primary care organisations and GP practices – need information on performance and productivity to decide how to get the greatest benefit from the resources at their disposal and how to allocate resources between different patient groups and types of care.

And at the top level, the government needs to know how productive the NHS is: how much health benefit the NHS is producing for the taxpayers’ funds it receives. Currently, productivity is measured in terms of the amount of activity in the NHS – numbers of patients seen and treated – but with no reference to how successful the activity is in improving patient health.

The OHE commission concludes that the reward for collecting, analysing and using data on patient outcomes across the whole range of NHS healthcare should be improved performance, better use of resources, and hence better care for patients.

But how and how soon can we measure patient outcomes? The OHE commission reviewed evidence on measures of patient outcomes in four ‘tracer’ disease areas: elective surgery, mental health, chronic obstructive pulmonary disease (COPD) and colorectal cancer. They cover acute and long-term conditions, primary care and hospital care, life-extending and quality-of-life-improving care.

There is a lot of evidence demonstrating the feasibility of collecting and using patient outcome measures but so far this has only been done in the context of discrete, one-off projects such as clinical trials. Based on the evidence, the OHE commission concluded that routine measurement of patient outcomes in the NHS is both practical and essential.

Outcomes measurement is possible in all types of NHS care. As Nigel Edwards, a member of the OHE commission and policy director of the NHS Confederation, put it: ‘Although the methods are not perfect and there will be gaps where measurement will always be difficult, this is a classic case where the best should not be the enemy of the good. Starting to measure and use the results will lead to a far more rapid improvement in data quality and measures than could be achieved by simply continuing to talk about it.’

Managers and clinicians both need to understand the importance of and support measuring the outcomes of healthcare for patients. If clinicians do not see the benefits of the measures then adequate data is unlikely to be collected. Clinicians must be involved in implementation. This is most likely to be achieved if there are clinical champions to drive the use of outcome measurement, with the focus on enabling self-improvement.

Professional and public kudos for the clinical teams doing the work and for the commissioners serving local populations is a strong incentive. Receiving regular and timely feedback is also important for clinicians. Without this they will be unable to make decisions based on the data at the appropriate time and will see little point in collecting it. The data need to be presented in a way that individual clinicians, commissioners and providers can act on the results. The importance of suitable IT infrastructure and appropriately trained staff to enable this is clear.

The NHS should, as early as possible in 2008/09, pilot, monitor and evaluate explicit incentives to collect, collate, analyse, feed back and use patient outcome measures. Initially at least this would not be extended to rewarding providers for the measured levels of outcomes achieved, although that could be considered once experience with use of outcomes measures has accumulated.

In primary care, the quality and outcomes framework (QOF) of the GP contract could be a good tool. GP practices could be paid for achieving high coverage in administering patient outcomes questionnaires that enable collection of outcomes data.

Other commissioners and providers might be incentivised financially through a parallel arrangement. The Advancing Quality scheme being piloted in NHS North West is one example of a mechanism that could be adapted to that purpose.

The incremental running costs entailed in collecting outcomes measures may not be negligible, but very small relative to total NHS spending and to the importance of the information they will provide. Estimates vary between £3 and £6 per patient.

Although it is not practical to apply outcomes measurement everywhere at once, it is reasonable to expect that within five years patient outcomes data will be collected for most NHS activity.

The OHE commission is recommending the collection of both condition-specific measures of patient outcome – of the kind often favoured by clinicians as being most useful to them in assessing the impact of care – and generic measures of health-related quality of life from which QALYs (quality adjusted life years) can be estimated. Generic measures permit comparison and aggregation of outcomes across different types of healthcare.

As it is simple to use, requiring patients to answer just five questions, and is already the National Institute for Health and Clinical Excellence’s preferred quality of life measure, the OHE commission recommends the EQ-5D generic measure (see box) be collected. For acute treatments, outcome measures would be collected immediately before and three months after treatment. For chronic conditions the measures would be collected periodically – at annual check-ups, say.

Focus on wider benefits
In addition to patients’ health outcomes, the OHE commission recommends collection of data about the wider benefits from health services by adding questions on patients’ experience of care to the patient questionnaires used to measure health outcomes, as well as in patient and population surveys. Aspects covered should include:

• Access to care
• Co-ordination of care
• Autonomy, choice
• Communication
• Confidentiality
• Dignity
• Quality of amenities
• Support for carers.

More research is needed to identify the most practical way to collect data on the direct economic impacts of healthcare, such as reducing the numbers of days of sickness absence from work. This should also be attempted, and prioritised for treatment of patients with depression and musculoskeletal problems, as these are major causes of lost work time.

If within five years the routine measurement of patient health outcomes and wider benefits from healthcare has become the norm in the NHS throughout the UK, we will be a long way towards achieving better commissioning of healthcare, better performance of healthcare providers and better outcomes for patients.


EQ-5D quality of life measure
EQ-5D is a standardised instrument for use as a measure of health outcome. It provides a simple descriptive profile and a single index value for health status. It is designed for self-completion by respondents and is intended to be suited for use in postal surveys, in clinics and face-to-face interviews. The EQ-5D descriptive system comprises five dimensions of health:

Mobility
Self-care
Usual activities
Pain/discomfort
Anxiety/depression

Each dimension comprises three levels:

No problems
Some/moderate problems
Extreme problems

A unique EQ-5D health state is defined by combining 1 level from each of the 5 dimensions. For more details visit www.euroqol.org

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