How to measure for improving outcomes: a guide for commissioners

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Under the Health and Social Care Act, the NHS Commissioning Board and Clinical Commissioning Groups (CCGs) will be accountable for improving health and treatment outcomes in the NHS.

We've produced two slide sets to help CCGs make the best use of measurement to support them to commission for improved outcomes (the pdf versions on the right include explanatory notes - to access, click on the comments icon on the top left of each page).

Pick'n'Mix: an introduction to choosing and using indicators

Our first slide set introduces general concepts about approaches to measurement in health care, the uses of structure, process and outcome indicators, and how to achieve a good mix of indicators for commissioning.

Measuring quality along care pathways

Our second slide set looks specifically at how commissioners can build up sets of measures along whole pathways of care.


Dr Jane Robinson

retired professor of nursing,
save a Ludlow town centre GP
Comment date
06 August 2012
In my retired capacity I am involved in an attempt to retain a GP presence in Ludlow town (which has a disproportionate number of older people in a population of 10,000) when the two existing practices move out to a new site co-terminous with the new Community Hospital, on the town boundary.
As a resident in one of 3 blocks of flats for older people in Ludlow I am extemely concerned about the impact of this (and other) groups of extreme elders and the disabled who will be unable to use public transport because of mobility problems, and who will have to resort to taxis or home visits.
What sorts of outcome measures will the King's Fund or other agencies be developing to keep track of the impact of this policy on older and disabled people's access to GPs?

Tim Benson

Abies Ltd
Comment date
08 August 2012
I am concerned that these presentations make a complex subject appear to be even more complex than it should be. What we need is simple outcome measures, routinely collected as part of everyday practice. The problem is that most existing measures have been designed for use in clinical research, which, unlike routine care, has relatively few subjects and plenty of time. As Atul Gawande said, we need something as simple and effective as an Apgar Score for everyone.

Jonathan Miller

Cancer Network Director,
Peninsula Cancer Network
Comment date
09 August 2012
Re Pick ’n’ mix: an introduction to choosing and using indicators.
Thanks you for this, very useful review.
On a specific note slide 32 implies that screening has a role in reducing incidence. I am not sure how this might be. It certainly helps identify cancers at an earlier stage (and hence improving survival) but not sure how it would provent them arising in th first place (unless you count the identificaiton of pre-cancerous conditions)

Veena Raleigh

Senior Fellow, Health Policy,
The King's Fund
Comment date
14 August 2012
We are pleased that viewers have read and taken the trouble to comment on our slide sets on how to measure for improved outcomes and quality along pathways. The comments raise some important issues.

Whenever services are reconfigured or reorganised, it is important to ensure that no communities and user groups are unduly disadvantaged in terms of access to services - especially in the case of GP services, as they are the first port of call for most people. The King’s Fund’s role does not extend to developing outcome indicators, but we do recommend that commissioners should use appropriate tools to measure access to local services for all groups, particularly those with special needs, and take remedial action where access is compromised.

We agree that outcome measures are useful and have an important role to play. In these slide sets our aim was to suggest ways of using measurement to answer not just the “what” but also the “how” ie to inform how outcomes can be improved, including for example for people with long-term conditions. The slide sets are aimed especially at commissioners, who will need to use measurement in various ways beyond just measuring outcomes. The principles, first established by Donabedian, are in fact quite simple, and we are arguing for a return to them.

Re slide 32 (pdf version): Cancer screening does not impact on incidence. It was included among the population-based indicators, to differentiate it from the provider-based indicators, but we have amended this.

Mike Davidge

Head of Measurement,
NHS Institute for Innovation and Improvement
Comment date
18 August 2012
My comments are aimed at the second of these slide sets - measuring quality along care pathways. There is a lot of helpful material here and so I want my comments to be seen in the spirit of 'even better if'.

(1) Given that the subject is care pathways, it would have been nice to show how the various measures relate to a pathway visually. Care pathways generally follow the presentation - testing - diagnosis - treatment - discharge pattern so which measures are relevant at which stage? Without this simple visual it all gets rather complicated as Tim Benson commented earlier.

(2) Most people have trouble not with what to measure but how to do it effectively. At the risk of being accused of blowing my own trumpet, I would invite readers to view this short video which attempts to address that particular challenge -

Teresa Cresswell

Senior Public Health Manager - Lead for Children,
Derbyshire County PCT/DCC
Comment date
27 August 2012
Would welcome guidance and support on commissioning for improved outcomes for children and families via public health and the local authority. In particular looking at 0-19 provision as a single pathway.

Dr David Rapp

retired GP,
Comment date
03 December 2012
This process of measurement and guidance is all very well meaning,but please acknowledge the increasing pressures being put on GPs trying to make CCGs work.PCTs never had this degree of scrutiny put on them in the past.Obviously,GPs can start to address some of these issues but they are being expected to do more in Primary Care with less resources and there are only 24hrs in the day.All these expert "Chiefs" are very happy to pile more tasks on the ever stretched and reduced cohort of "Indian" GPs.I feel everybody,from the Government to the public need to be much more realistic and honest otherwise the whole edifice will come crashing down.Let the Government,for all its rhetoric, remember that there is an election in 2015 and if everything has gone pear shaped by them they should take the blame for creating the process in the first place.GPs do and should get involved but cannot control the whole system without greater support and time allocation to be able to do the job properly.Numerous "experts" put their halfpennys worth into the ring not appreciating that the GPs are being showered in Halfpennies from all directions at once.

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