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June 02, 2013

Process and Outcome

It's years ago, but I still remember the reception I received when during my first large-scale NHS IT implementation I suggested that doctors might like to record outcome information. I can still recall the smell of my singed fingertips. Until recently, the NHS has been obsessed with recording process data fitting an organization with its roots still in the mid-twentieth century.

General Systems Theory suggests a dynamic relationship between structure, process and outcome. So, if I change my operational processes to achieve a different outcome, it is likely that I will also have to change the structure of my organisation to accommodate it. Alas, healthcare seems to constantly mix process and outcome, often throwing ‘quality’ into the mix to make an even bigger muddle.

Process measures consume the NHS: numbers of patients, numbers of procedures, waiting times, bed occupancy rates - so much so that they have obscured what health services should be about: either preventing us from becoming unwell, or, failing that, making us better again quickly. My consummate outcome is to live a long healthy life, dying after a short illness. Of course, not everyone (including me) might be that fortunate.

More recently we have had the blunt measure of mortality rates. On its own that has been enough to identify departments and whole hospitals that were under performing, and to elicit a fast response. And we are still reeling from the Francis Report which criticised the Mid Staffordshire NHS Foundation Trust and the culture of the whole NHS. If mortality rates alone can identify such shortcomings and bring about this response what may more sophisticated measures do?

Also, in recent years the NHS has focused on more granular process measures, such as those used in the Quality and Outcomes (QoF) framework, which is meant to assess the service provided by GPs--and is also the system by which they get paid. You can see a menu of these indicators on the NICE website .

The titles look promising, but the measures underlying them are really measures of process, not outcome. In the main they measure what a practice or practitioner does, not how successfully they do it or what effect these actions have on the health of their patients.

Patient experience is another expression in vogue. The thing is as a patient I can have a great experience - be treated with the greatest of respect by people; housed in a beautiful ward; and served gourmet food. But how does that rate with the the importance of my being diagnosed correctly and receiving the best intervention or treatment for my condition? Ultimately, patient experience is entirely subjective. I would tolerate a poorer experience if I could be assured of the best possible outcome for my condition.

I went to the Information for Commissioning conference organised by E-Health-Insider the other week - one of the best conferences I have attended in a while mainly because of the healthy tension I sensed between the old and the new. The one (by far the most popular with the audience, I noted) promulgating the notion that there is nothing much wrong with the NHS and suggesting that the current spike in emergency department attendances did not mean the whole care system was on the brink of collapse. The other holding an opposing view - the NHS was rapidly running out of time and money and needed some profound change if it was to survive. I was particularly taken by a pair of presenters from the Kent and Medway telehealth initiative who talked a lot of sense about the ascendency of remote care and the means to fund it.

No prizes for guessing where my sympathies lie, then. Anyone who believes healthcare can continue to be delivered with the current model needs a very strong coffee. The recent spike in emergency attendances, though it has abated, is just a foretaste of what is to come. For too long emergency departments (and acute beds) have been used to buffer an inefficient and obsolescent care system that is all too unready to cope with the sharp change in epidemiology building inexorably as a consequence of an aging, overweight and chronically ill population.

At the EHI conference it was also good to hear that NHS England intends to place greater emphasis on the measurement of outcome, these measures eventually being applied to organisations, specialties and even individuals.

Some promising signs of a co-ordinated approach are also about with the Secretary of State for Health announcing an increase in the number of GPs and specialist nurses with the aim of sandbagging the rising tide of demand. Also greater incentives to use telehealth are mooted for inclusion in GP contracts. However, getting those changes over to an organisation still mired in the management methods of the industrial age is going to be difficult.

My book, which addresses some of the issues, 'Stop Saving the NHS and Start Reinventing it' is available in Kindle and paperback editions on Amazon.