Measuring accountability for outcomes: is transparency enough?

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Transparency is critically important for both health care quality improvement and informing patients and the public about what they can expect from the NHS. However, just publishing information is a soft form of accountability. The NHS Commissioning Board, clinical commissioning groups (CCGs) and providers need to be held to account, with plaudits if they excel, and consequences if they fall short of expected standards. Lack of a measurable expectation of stretch can leave the government open to challenge on its assertions about NHS performance in the future.

The government is committed to greater public information on NHS performance. In a new development, referred to by Jeremy Hunt when he spoke at our annual conference last week, the government has commissioned a review of whether and how ratings similar to those  published by Ofsted could be produced for hospitals. While providing a single rating for an organisation as complex as a hospital is fraught with challenges and risk, this is intended to act as an important driver for improving performance.

Regardless of the conclusions of the review by the Nuffield Trust, the Department of Health and NHS Commissioning Board are already committed to greater transparency. At provider level the Department of Health’s NHS mandate commits to publication of outcome data for ’all major services by 2015’, broken down by CCG and by clinical team, to reduce unwarranted variations in the quality of care. This will be supported by strengthening quality accounts, which all NHS organisations have been legally required to publish annually since 2010.

Greater transparency of data on health care outcomes will support NHS staff and organisations in improving health care quality, patient choice and public accountability. But again the ’how’ is important. Their content and presentation format needs to be refocused, with greater standardisation of content to include robust, quality assured information on a core component of outcome indicators that all organisations are required to report on, as we discuss in our report on how quality accounts measure up. To be meaningful to readers, the data needs to be benchmarked against national and peer comparators. If the information is to be clinically credible, greater use of clinical audit data and more rigorous assessment of data quality is imperative. Organisations should also consider including information on evidence-based clinical processes of care – such as the proportion of patients with diabetes who receive all nine recommended tests annually (see our slidepacks on how to measure for improving outcomes for more).

The mandate also sets out the objectives that ministers will use to hold the NHS Commissioning Board to account over the coming years. The NHS Outcomes Framework defines the outcomes that will be used to assess national performance of the NHS, and it's a good selection, covering a broad range of health care issues and avoiding a narrow focus.

However it is not clear how the future performance of the NHS – nationally and locally – in achieving these principles will be judged. What rates of change in the indicators constitute acceptable performance?  Most indicators already show an improving trend – so is continuation sufficient, or are we to expect a faster or slower rate of improvement in future?

The Department of Health is right to have dropped its earlier plans which were complex, opaque and open-to-challenge. However, the pendulum may have swung too far the other way, as the mandate now only requires the Board to make progress (variously defined as good/significant/rapid progress, or just progress) on these indicators. Although there are ’stretching ambitions to be among the best in Europe for key priority areas’, it is not clear what rate of progress is considered acceptable for the investment of over £100 billion annually in the NHS.

The Commissioning Outcomes Framework (COF) will be used to assess the performance of clinical commissioning groups (CCGs) locally towards national goals. The COF indicators under development by the National Institute for Health and Clinical Excellence have undergone a rigorous process, and the proposed set thus far looks promising. But again, it's unclear what measurable rates of progress will be expected of commissioners.

While the drive on transparency of information on performance is welcome, clarity about performance expectations is also necessary in order to avoid future ambiguity and controversy about interpretation of NHS performance as good or weak.


Liz Bywater

Comment date
05 December 2012
I am in the process of attempting to raise awareness about the absolute relevance for follow through data/qualitative research/ clinical trials in respect of some aspects of gynaecology surgery.(specifically rectocele repair surgery - Royal Derby Trust) I beleieve that this area requires serious reappraisal for the benefit of women attempting to make informed choices)

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