How can the performance of local health systems be assessed?

Today we publish the results of our review of how the performance of local health systems could be assessed. This work was commissioned by the Department of Health which asked The King’s Fund to advise on the ‘first principles’ of a local health system scorecard for the NHS in England.

We were asked to report on the development of a health systems scorecard which would aim to:

  • allow commissioners to assess the quality and effectiveness of local services and identify areas for improvement
  • provide accountability to patients and the public, allowing them to compare local health services on the basis of objective information
  • help NHS England identify areas where clinical commissioning groups (CCGs) may need targeted support to improve care quality and health outcomes.

The review is a contribution to Secretary of State for Health Jeremy Hunt’s ambition to put ‘intelligent transparency’ at the heart of NHS performance improvement in this parliament. We believe intelligent transparency demands a clear line of sight from the Secretary of State through NHS England and CCGs to the populations they serve, based on indicators that reflect what really matters to the public and NHS priorities. This would deliver the single definition of success for local systems of care and CCGs that the Health Secretary has spoken of as being needed for providers.

To deliver this clear line of sight, we recommend radical simplification and better alignment of existing frameworks for assessing performance in the NHS. Our report also argues that there should be rationalisation of the disparate public-facing websites to provide the public with an integrated view of health and care services in an area. The public should be consulted on which aspects of performance should be covered and how information should be presented – at the moment this is an evidence-free zone.

Intelligent transparency demands careful attention to how performance indicators are selected and presented if it is to achieve its desired results. Done well, performance assessment can help to strengthen accountability to patients and the public, as well as support commissioners and providers in improving care. The challenge is to adopt an approach that recognises the complexity of performance assessment and the pitfalls that await the uninitiated.

To avoid these pitfalls, we looked at experiences in a number of other health care systems as well as in the English NHS. We recommend that information about the performance of local health systems should draw on the three national outcomes frameworks that currently exist and the commissioning outcome indicator set. This information should be presented at three levels to inform patients and the public about services in their area and to support commissioners and providers in achieving improvements in care.

The first level would focus on a small number of headline indicators aimed at providing a picture of performance for the population as a whole. The second level would be organised around the domains and indicators in the outcomes frameworks and the commissioning outcome indicator set. The third level would include a larger set of indicators to enable patients and the public to drill down into population groups and medical conditions of particular interest to them, and to support commissioners and providers in quality improvement.

Over time we recommend that the three outcomes frameworks be consolidated into a single framework covering the NHS, adult social care and public health.

One of the clearest conclusions of our review is that an aggregate score of the performance of local health systems should not be produced using performance indicators alone. Aggregate scores can mask good or poor performance on individual indicators and therefore may not give a meaningful overall picture. This was strongly supported by our review of the evidence and experience in other countries, as well as by the group of technical experts that we convened to advise us in our work.

Further work is needed to understand more thoroughly the information that the public and CCGs want, as well as how appropriate data could be presented and accessed to support the causes of transparency and improvement.

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In Scotland we think we have cracked the nut of the aggregation from individual to service - even to the population as a whole.

We can see performance over time at any level, and as time moves on the data just gets richer and richer. A big step from looking at bed days as the performance measure to using functionality - concentrate on that and the bed days will fall away.

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