How do the Commissioning Outcomes Framework indicators measure up?

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From 2013 we will hear a lot more about the COF – not a seasonal viral epidemic, but the Commissioning Outcomes Framework. The COF will be used by the new NHS Commissioning Board to assess the performance of the 212 clinical commissioning groups (CCGs) who will take up their responsibilities as the purchasers of health care for local populations from next year.

The COF will measure the quality and outcomes of health care commissioned by CCGs, and will be used to hold them accountable. The National Institute for Health and Clinical Excellence (NICE), which was tasked with developing the quality and outcome indicators in COF, has recommended 44 indicators to begin with. The NHS Commissioning Board will decide the indicators to be used in the 2013/14 COF.

There is much to be welcomed in the indicators proposed by NICE. They map to the NHS Outcomes Framework and cover a range of patient groups and conditions. They include indicators for mental health and maternity, which are often overlooked in accountability frameworks. The indicators are based on sound evidence and expertise from a spectrum of stakeholders, including clinicians and patient groups, so they will have clinical and public credibility. The use of some process indicators is welcome, even if NICE is unnecessarily bashful about their inclusion where outcomes are not available. Indeed, in a recently published slide set for CCGs, we noted the limitations of focusing purely on outcomes and advocated a diverse approach to measurement. The indicators have also been subject to feasibility testing by The Information Centre. So, overall, a sound process and a promising start. But is it enough?

The COF reflects yet again the problems resulting from the government’s early decision to have separate outcome frameworks for public health, health and social care. Although the proposals reflect the limited remit that was given to NICE, they focus largely on long-term conditions and treatment while neglecting prevention (although some indicators have a preventive dimension). The government maintains that CCGs and general practice will have a public health role in the new NHS – for this deliverable to have teeth, indicators relating to public health must form part of the COF and not be seen as an adjunct.

Furthermore, there are gaps in the proposed indicators, for example, children and young people and learning disabilities are poorly covered. The imbalance is striking given the focus on some areas – for example, 8 of the 44 indicators relate to stroke. The gaps reflect in part the lack of evidence and/or data, or problems in reliable statistical measurement of indicators at CCG level. The COF’s scope will also widen as NICE develops further quality standards, so the balance should improve over time. But in the interim the assessment of CCG performance can only be partial and carries the risk of distorting CCG priorities. A less purist, more pragmatic approach to indicator selection could help fill some of the gaps in the short-term.

Many aspects of how the COF will work in practice remain unclear as yet – which indicators will the NHS Commissioning Board approve, what else will go into the COF, what penalties/rewards will there be for under/over performance?  And how will CCG performance be judged in other areas, such as reducing inequalities, prudent financial management, organisational robustness and integrated ways of working? A holistic and integrated approach to assessing CCG performance will be critical for holding them to account, and for ensuring that the different components complement each other and avoid unintended consequences. Finally, what is the relationship between the COF and the levels of ambition that will be set for the NHS Commissioning Board in the mandate?

The COF is a powerful lever. It will play a key role in determining the pace and shape of CCG performance in commissioning and delivering on the government’s goals for the NHS. It will also indirectly influence the role played by general practice. NICE has given the COF indicators a healthy kickstart, but much depends on making them more comprehensive and ensuring prevention gets a square deal. Finally, the COF’s success will depend primarily on the manner of its implementation and how it will work in practice.

This blog was also featured on GP magazine website.


Bobbie Jacobson

London Health Observatory
Comment date
15 August 2012
This thoughtful commentary of the COF is spot on. DH did not reveal at the time the huge number of organisations that responded to consultation on the Outcomes frameworks by recommending integration. While there is now more overlap- the ownership for improvement must be shared, and performance management frameworks need to recognise that. The evidence shows that the causes of inequalities in health outcomes are shared across frameworks and cannot be boxed into one sector or other alone.

Jane Roberts

Comment date
16 August 2012
I agree with Bobbie's comments. Of course, PCTs, co-terminous with local authorities, were in a better position to bring together public health and social care with health care. Apart from this, the description of the COF is much as I remember we were doing in PCT commissioning....remember World Class Commissioning? PLus ca change (at great cost)...

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