“We are too focused on inputs and not outcomes, and the real value of place”
NHS Trust CEO
Starting with outcomes
Introduction
Throughout the engagement for this programme, an ‘inside-out’, outcomes-based approach resonated strongly with local systems.
Many leaders reflected that while prioritising outcomes is often talked about, in practice it is much more difficult to do. All too often change is initiated from the outside, with new processes and services being put in place because they provide a ready-made solution.
It was suggested that while many providers may have been implementing service changes, the crucial link to measurably improved care for people is sometimes lacking. There may well be positive intent with some target outcomes agreed. However, as work progresses, systems can lose focus on the specifics of outcomes. It was reported that a generic targeting of ‘better outcomes’ does not have the impact to drive the system to reach the level of improvement that could and should be achieved.
What does ‘starting with outcomes’ mean?
There are some key steps to make sure systems are set up for success; in a complex environment it is important to establish whether these are in place across the system.
Three critical elements were commonly found in systems which ‘start with outcomes’ and are explored in further detail here. Although they may seem straightforward, some systems observed how time pressures and the focus on the short-term had proved to be a distraction, preventing them from building the right foundations.
SPECIFIC FOCUS
Many systems engaged through this programme raised the issue that while the purpose of partnership working was being described at a high level, what needed to happen was agreement on a specific focus that will drive delivery.
“There is a risk that everyone integrates, the new structures are described and put in place, but actually we’re not really population focused. We might orientate around structures, but we won’t be clear enough or specific enough on the purpose of doing it. We’d be better off squabbling but focusing.”
Chief executive, Community NHS Trust
Systems that ‘start with outcomes’ define the purpose of coming together with partners to work at place and are as specific as possible regarding what is to be achieved in terms of an outcome. Most place-based partnerships have an articulated vision informed by system and local priorities. There is sometimes a gap, however, between this vision and the practical delivery required.
The missing element is the identification of the specific improvement being targeted and a delivery plan to realise the benefits. Leaders of systems frequently mentioned that while they had thought that they had articulated a clear purpose at the beginning of their integration journey, they subsequently realised this had been pitched at too high a level or had simply comprised a series of inputs rather than the desired outcomes. As a result, leaders had encountered challenges when seeking to clarify and drive the operational changes to ensure better care would be delivered in practice.
Experience shared through the programme, including from the reference sites, has shown that where systems or change initiatives have an input-based purpose such as “to set up this new service” or “to bring these teams together”, there can be a similar lack of clarity. Equally, it can be particularly challenging to focus effort on the right place when the purpose is too generic – for example, having a purpose of “to improve outcomes” is unlikely to provide an appropriate level of focus to deliver improvements.
“Saying you want to make everyone healthier is not a purpose around which you can integrate.”
Chief executive, Community Provider
In systems that ‘start with outcomes’ leaders agree the purpose from the outset – “this is why we are doing this”. They are also specific on the detail of what outcomes are to be achieved for people. Their purpose might describe a future achievement, perhaps linked to the population being served. It can be short and in straightforward language such as:
To reduce the overall cost of long-term care in the system to ensure long term financial stability and investment in new priorities.
To ensure everyone receives the same high-quality care and support regardless of place, time, or person.
To reduce the number of people being admitted to hospital when that isn’t the best setting to support their care.
To support people to be as independent as possible in the community.
It may be a combination of the above, or many other things.
evidence and opportunity
Many local teams engaged through this programme shared challenges in gathering reliable and consistent evidence of what their current performance is, and what it could be. Even for systems with good quality data and reporting, it was agreed that it is rare to find existing data that illustrates the gap between current and potential performance, that sheds light on why that gap exists.
Systems that ‘start with outcomes’ establish the evidence of what could be better. Knowing that there is a possible improvement to be made, and how great that improvement might be, allows them to prioritise resources in the right place. This ensures that partnership working for any given pathway or service has a measurable and positive impact for people.
Ideally, the evidence is independent of organisation and service; an objective truth, backed up by data that everyone believes in. This provides an evidence-based starting point for identifying the issues and processes that need to change.
“There is a risk that everyone integrates, the new structures are described and put in place, but actually we’re not really population focused. We might orientate around structures, but we won’t be clear enough or specific enough on the purpose of doing it. We’d be better off squabbling but focusing.”
NHS Trust CEO
A strong evidence base brings many benefits, in particular:
Confidence that an improvement can be made for people and the care they receive.
Confidence that resources are being committed to where a real difference can be made.
Ability to prioritise programmes based on the impacts they can generate.
An objective truth that different organisations, leaders, and frontline staff, can share, refer to, and have as a starting point of common ground.
An independent anchor to galvanise the purpose of the programme or change, unrelated to a particular organisation or agenda.
An ability to quantify or estimate the expected future impact on people, operations, and finances.
Shared learnings on what to consider when building the evidence base
The following learnings have been drawn together based on the engagement and input into this programme of work.
Capture more than simply whatever is happening right now. Capturing evidence of current performance as well as evidence of what could be achieved with improved performance and different ways of working, enables the case to be built for the opportunity to improve.
Use detailed case reviews with frontline staff to build a strong case for improvement. Capture data not available elsewhere from these cases, rigorously, to quantify what could be improved and the extent to which the improvements could be made.
Aim to triangulate using multiple sources of data and insight, recognising different data sources will have different resonance for different stakeholders. Avoid using any data source where people have historically questioned the accuracy.
Some of the data or evidence required may not exist in a useful or accurate form. It is worth investing in collecting required evidence by new means, such as detailed case reviews, studies of frontline decisions to validate data, or new digital systems.
Population health data and other wider datasets can be used to identify inequalities, for example, where there is no reason outcomes should be different between or within places or systems. Benchmarking in this way provides a high-level indication of the size of the opportunity to improve, which can be backed up effectively with detailed, local evidence and case reviews.
Measures of Success
As well as starting with an outcome-based process, systems that ‘start with outcomes’ revisit these outcomes frequently and measure their impact. At the beginning of any programme to integrate at place, the outcome measures are tightly defined, based on the evidence base of what can be achieved, with frequent and rigorous reviews to ensure that the focus remains on achieving that level of improvement.
Many systems engaged through this programme described how they have found it challenging to agree a concise and meaningful set of key performance indicators (KPIs). As a result, this risks frontline design diverging from the initial ambitions.
In one of the systems interviewed, leaders shared how they initially set up a new integrated community service with 55 defined KPIs. Many of these performance measures were already collected by individual organisations, but few of them were linked to the purpose of the new integrated service in terms of specific outcome improvements.
COVID-19 derailed many of the measures, while 55 KPIs in total presented a challenge in terms of seeing clearly whether the change was having a positive impact on outcomes for people. After adapting over time, the partnership now measures specific outcomes where the work has had a real impact – for example, the number of people now supported at home that would have previously been in hospital. Leaders shared the difficulty and importance of getting the measures of success right.
“We measured KPIs, lots of them. We produced and reported them through the board. But I don't think we did enough on outcomes.”
Director of strategy and integration, ICB
Shared learnings on what to consider when developing measures of success
The following learnings have been drawn together based on the engagement and input into this programme of work.
It may not be possible to track the ideal measure of success currently, but it is worth exploring investing in new ways to capture the data.
A small number of well-defined KPIs tends to be most effective. Often, programmes have dozens of KPIs requiring much effort to gather and interpret, and which lack precision in illustrating how services are performing and the impact of the partnership working on outcomes.
KPIs that can be measured and acted upon at pace, sometimes on a weekly or daily basis depending on the service, will support faster iteration of ways of working. A six-month pilot with evaluation not undertaken until the six months is complete will give a slower model of progress and adaptation, less understanding, and most likely a reduced overall impact.
As well as making sure the operational KPIs show that a desired level of improvement is being achieved, it can be helpful to incorporate the four areas of measurement below to measure the progress of place-based partnerships:
Consider the connection back to the specific focus of the partnership working, and to the place vision, on a regular basis. Meaningful measures of success should give confidence that if they improve, outcomes will be impacted directly and positively.
Keep the operational KPIs as simple and tangible as possible – the more relatable they are to frontline teams, the more likely they will be understood and focused on day-to-day decision-making.
We hope that this publication will not be the end of the programme, but the beginning of a conversation. A series of events will be available to attend to explore the themes in greater detail and share experiences.
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