5. Outcome indicators

by Department of Health on 04 August 2010 | 24 comments

What potential outcome indicators, including methods for selection could be presented in the framework?

Taking the proposed structure of five high level outcome domains as a starting point, what overarching outcome indicators could be developed for each domain; a method for selecting the specific improvement areas within each domain; and, based on that method, what are some of the potential improvement areas and their supporting outcome indicators.

Further information can be found in the consultation document on page 18, Chapter 3.

Please add your comments below.


  1. Use a better system for regulation of Trusts. Abolish the time consuming ineffective PHSO which achieves little and is itself cumbersome and not regulated. Its caseload is only a fraction of what the HCC did with more accountability. Use local panels to monitoe health provision and conduct with set timescales.

    Greater transparency in the decisions made by Trusts would help – given to the newspapers to publish not just available for those who persevere with internet seraches! Publish the statistics from hospitals on mortality, infection etc. then we can make informed decisions.

  2. Monitoring the outcomes indicators could lead to a large increase in the data collection burden being imposed on NHS Trusts. Will the NHS Information centres Review of Central Returns team still be in place to approve requests for central data collections from the NHS. Their role in protecting Trusts from requests for duplicate data item and making sure data is collected efficiently is seen as invaluable by my Trust.

  3. I would like to see people with learning disabilities included under the “vulnerable groups” section (3.63) – the reports “Six Lives” and “Death by indifference” demonstrate the need for this.

  4. It is more sensible to measure meaningful, functional goals for people with long term conditions, rather than just measure how quickly people are seen and then for how long they are seen for. If you just measure (and cap) timescales for intervention then as therapists we are unable to respond to a persons needs and fluctuations. I work for a community, neurological rehabiltation team and we are measured on the percentage of our goals that our clients achieve, goal setting is collaborative with clients and we document this information anyway so it is not extra work to measure goals achieved.

  5. In general the document is sound and I agree with it up to the point of outcome indicators. My concern is the suit of quality standards to be drawn up by NICE. Having read the VTE, Stroke and Dementia standards these in effect amount to care pathways for these areas. As a GP commissioner if my success is to be judged by these micro-management care pathways I shall have to spend time ensuring that the providers stick to and measure these standards. The result will be a bureaucratic machines in both the commissioning and provider organisations servicing the standards. This will be a slow, expensive, time consuming, management driven, clinician emasculating, moral sapping, innovation draining waste of time. This is new labour top down and not required.
    My suggestion is to measure us against the very sensible outcome indicators and to leave it at that. The quality standards should be published as resources for commissioners and providers to draw on and not be measured against. I speak from the experience of being a GP servicing the QOF indicators, which define the shape of my organisation in those areas and in some cases lead to a poorer patient experience and clinician disengagement.

  6. I agree with Chris Mills – compliance with the standards could so very easily be interpreted as providers having to record compliance with each micro step of the pathway – currently only 3 NICE standards published; Para 3.12 of the White Paper envisages 150 such standards over the next 5 years.
    Remember the industry that grew up around the micromanagement of the 18week RTT pathway and the complexity around recording every clock start, pause and stop . . .
    Compliance with 150 NICE Standards could be tied in with an organisations Clinical Audit programme

  7. There is very little in this document about palliative and end of life care. This has been an important but under-recognised area, and is becoming increasingly important with the increasing numbers of elderly people. There really should be measures included to cover this area, perhaps covering: preferred place of death, care provided for family, etc. It may be that this is not seen to be an NHS issue – the Hospice Movement takes the lead, but it is, after all, a critically important part of healthcare provision – is the government going to take a patient-led approach or an NHS-led approach?

  8. One simple observation: It has proved nigh on impossible for Trusts to report effectively on re-admission rates for years because of the quality of data, a clear definition of re-admission and the lack of visbility of data outside of the hospital environment that may impact on the need for re-admission. How will these issues and any others that will affect the majority of the outcome indicators be addressed and monitored to ensure cosistent measurement and reporting and, more importantly, a consistent view of performance that patients can base their choices upon.

  9. A lot of words, all with good intentions – call me cynical, but making it happen is another matter! I agree with Peter Edwards comment about lack of emphasis on end of life care. If hospices are expected to continue to take the lead, they should be funded accordingly, rather than having to rely on charitable donations.
    One other major area of concern – if NHS is to be more patient focussed, how will these proposals enable indiviuals to have more influence with regard to funding decisions for new facilities? e.g. since Hertfordshire does not have any radiotherapy facilities of its own, those requiring such treatment are obliged to travel to Mount Vernon in Middlesex. The stress involved in making such a long and unpredictable journey results in many people deciding to decline a treatment that could have extended their life. This is particularly true for the elderly and for those who are unable to drive. There is currently a proposal to establish a radiotherapy unit at Lister Hospital in Stevenage, but apart from signing a petition in support of this, I can find nothing in the ‘Liberating The NHS’ document that will enable me, as a client, (and a tax payer!) to have any meaningful effect on the decision making process. 1 in 3 people are affected by cancer and survival rates in UK are poor. I am yet to be convinced that anything in the above mentioned document will change this state of affairs.

  10. mearsuring outcomes are necessary and important for feedback. It is important that abilithy to collect and logistics of doing so is considered.
    current evidence on PROMS suggests that ti is very time consuming and expensive drawing indivicuals away from frontline. The NHS as a whole is still strugglng with good IT systems, coding issues etc to develop detailed data collection or numerous one. The principles are often sound but reality not quite the same…….. difficuties and anxieties for most…….

  11. 2.32 correct to state that risk and limitations in focusing on some outcmes can potentially distort by concentration on some areas. However, where is the evidence of that? even broad suvreys, or crude measures are affected by overall quality. if technology is not fully available and data EASY to collect, it is better to work on particular areas at a time and work through all if that is the approach.

    promoting effective practice – need a better way to do so than current

  12. 3.9 question 9
    Important to define how we measure either mortality or survival in cancer. lots of factors affect this – from lifestyle through to treatment. who is being measured here. NHS or success of prevention? or referrral? or acute care. each area is important in the chain…..

  13. 3.12 question 11. difficult one survival in older people is affected by previous lifestyle and in present day by the preventive measures taken currently. Many elderly lives alone with little support. ultimately die because of poor social circumstances, falling in home or outside.
    Hospitals are no place for elederly once acute conditionns are treated. need to consider measures to change delays in getting these individual out of hospital. and what preventative treatment is there in the community.

  14. 3.13 q 12 yes resp diseases in young childeren. what promotion and success is there for education of parents who smoke in the presence of kids. what measures are there to look at home environment that may promote resp illnesses?

  15. 3.28 q 16 — what is an acute condition and a chronic condition in adultes that ca be cured by hospital admission? Mony adult diseases in the west are those of chronic illness, lifestyle or social. heart disease, stroke, cancer, chronic resp illnesses. the is less of acute infective illness without underlying conditions. similar is seen in surgical specialties.

    Management of acute episodes with or without underlyinig chronicity needs to be considered. repeat adm is also often affected by what patients do after admission. – not an easy one to estabish. paramaters should be on criteria for end of treatment or similar

  16. q 18 PROMS — logistics of data collection and the host of issues involved MUST be considered otherwise this will become a irritating burden. evidence on surveys eg shows that even with incentives, 65% return is best achieved, yet the NHS evidence says collecton should be 80%. the post op return is even lower. curious that national polls etc are sensitive by random sampling. why can’t we use random sampling of smaller numbers – these will give same data and easier collection…
    make it simple to both collector and individuals who fill forms in.

  17. q 18 fracture hips the national fracture hip database gives excellent measures on where to start…

  18. q 19-21 agree with survey of users. however disagree with the depth of detail. ANY survey that is validated will be useful if the results are acted on. It is not an unusual comment that the survey is too broad and doesnt reflect a subspecialty area. However the time and effort in beinng more detaled is important to consider in terms of effort and yield from it. The evidence on survey does not support the depth. the view is based on lack of understanding. It is also important to have an NHS standardised one done at the same time. If every area does an action plan on the outcome it will be more time effective. education is needed on this in terms on how much depth we go into.to make it practical.

  19. q 23 yes definetly — children and adults, elderly care. acute and chronic. community, a&e, acute in pt and elective. broad areas that would be a good idea to used. the principles in these areas are the same.

  20. q 25, 26 yes
    27-31 need to consider if organisations have the framwork for looking at all aspects. the expectations and requirement will have to be matched by ability to process data – many are simply not setup to do so.
    population education is as vital in this process rather than merely focusing on the providers of care. expectations need to be matched.
    the overall approach is good but a concern about the planned depth and ability to deliver. current PROMS an CQINNs are early indicators of concerns….

  21. Outcome frameworks are all very well for patients and services where outcomes can be measured and attributed with some degree of confidence to specific actions. However working in chidren’s community health, much of the work is about health promotion and preventing future health problems. Short and medium outcomes are therefore difficult to measure. What therefore happens is that such work is greatly devalued – and may not be commissioned or that a long winded, fruitless and expensive search will be made for the much neded outcomes.

  22. At 2.21, the paper comments on international comparisons. It has been suggested that survival rates from cancer would be an important outcome, for example 1 year survival & I would agree with this. However in order for survival rates to be meaningful, it needs to be a statuatory requirement to report a diagnosis of cancer or we will not be comparing like with like. At present the recorded date of diagnosis may not always be the date the cancer was first detected but could be the date of relapse or even of the terminal phase of the disease. Only be correctly recording the date of initial diagnosis can we be certain our statistics are correct.

  23. It should be simple matter with current IT to provide a transparent summary of care at the end of each encounter (either on paper or electronically or simply stored until the patient requested a report). The GMC already expects patients to be allowed participate in ALL decisions regarding their care. This includes discharge from hospital; a transparent discharge summary would make it easier to judge its appropriateness and the thinking at the time if the patient has to be readmitted. If the document’s content is coded in the normal way in primary and secondary care, the completeness, accuracy and quality of its content can be audited easily. This would be welcomed by all professionals whose aim it is for the patient to get the best care.

  24. Section 2.4
    More detail is needed on the links between local authorities and the NHS, with specific measures for the joint working accountability. As the overal between NHS delivery and LA public health work grows larges due to the growth of the elderly population more joint working is needed.
    Section 2.25
    How have the outcomes framework domains been decided. As the NHS is driven by these primary domains it is reasonable to expect more consultation on the framework domains presented within the White Paper. We as that this area is debate more fully at committee stage to ensure it reflects the NHS priority setting process.
    Section 2.29
    An outline process is needed to show how NICE Quality standards will help to deliver each of the outcome indicators. As the outcome indicators are broad a clear NICE
    Older people and premature deaths – any area where death is avoidable through better care – such as unexpected death in epilepsy – should be more of a focus indicator. Epilepsy appears in the long terms indicator but also needs to be in the preventing deaths domain too
    There is a great need for PROMs development in areas where quality of life is affected – so cognitive function in CNS, particularly epilepsy, where newer drug treatments may have outcomes benefits that are not captured in strict disease measures such as seizure freedom
    A framework and timescale for measures development should be outlined in the document. A 5 year review of domain, improvement areas and quality standards needs to be outlined to ensure that we have the right discussion around the initial choice and then the refinement of these areas as technology and appraisal evidence develops
    Annex A, section 3
    Epilespy, as an area with significantly above average mortality should be specified as an improvement area in domain 1
    Annex A, section 4
    The improvement area in epilepsy is unclear as to where the aim is “seizure freedom” or simply recording the levels of “seizure freedom”. An aspiration for all patients to be seizure free and setting this as the aim for epilpesy treatment will significantly improve the focus on a tangible patient outcome and link to PROMs and recent guidelines in epilepsy. A siezure freedom rate should be listed as the improvement indicator.