In a consultation process commenced last autumn, the Department of Health in the UK proposed that the NHS should be evaluated based on an outcomes framework structured around five high-level outcome domains, writes Conor Hannaway.
Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime. This ancient Chinese proverb captures nicely the difference between outputs and outcomes. Sometimes short-term interventions are essential. There may be no other way to save lives than by supplying immediate aid. However, problems will persist when the measure of success – the outcome – does not focus on the underlying nature of the problem.
Many medical interventions can be viewed in the same way. An outcome such as a healthy population is more likely to be achieved through population health initiatives than by enhanced surgical procedures. Such a perspective does not denigrate the contribution of excellent surgery within medical practice. It simply highlights the importance of focusing on outcomes in any strategic intervention.
Even when we move into the world of medical interventions, having a balanced focus on outputs and outcomes, is important in terms of evaluating overall performance. Outputs are best viewed as the units of delivery of a service. Outputs are usually tangible. They may be measures of throughput. Examples include the number of discharges or number of procedures carried out. Outputs may refer to the range of services provided or to the hours during which a service is available. Outputs are usually measured in terms of quantity, quality, timeliness and cost. At a more fundamental level, outputs ought to be assessed in terms of the outcomes to which they give rise.
Outcomes are the ultimate measure of performance. Frequently, outcomes are the consequence of a number of complementary outputs. For example, research in the US shows a 1 in 5 rate of hospital readmissions amongst Medicare patients. Readmissions are driven by a combination of the quality of the medical care, the discharge protocols used and the care available to the patients within the community.
There are three measures which can be used to evaluate outcomes: efficacy, effectiveness and efficiency. Efficacy refers to the potential which a procedure has to treat a medical condition. It is usually determined during developmental research and in trials. However, real life effectiveness may vary due to the impact of intervening factors such as the context in which the procedure is implemented. Finally, the efficiency of the procedure can be measured by way of cost/benefit analysis or alternatively by comparison with other procedures.
There are three measures which can be used to evaluate outcomes: efficacy, effectiveness and efficiency
Outcomes are the unit of currency of clinical audits. In this context, it is important to note that there can be a complexity in evaluating medical procedures in terms of outcomes. For example, how should a procedure be evaluated where it can be shown that it is highly efficacious in treating a medical condition but carries greater risks to a patient than a less efficacious procedure. The other dimension, which needs to be considered, is the possibility of evaluating multiple outcomes.
In a consultation process commenced last autumn, the Department of Health in the UK proposed that the NHS should be evaluated based on an outcomes framework structured around five high-level outcome domains. These outcomes are intended to cover all aspects of the work of the NHS The five outcome domains proposed are: preventing people from dying prematurely, enhancing the quality of life for people with long-term conditions, helping people to recover from episodes of ill health or following injury, ensuring people have a positive experience of care and treating and caring for people in a safe environment and protecting them from avoidable harm.