Outcomes based commissioning

It’s back. It never really went away, or actually never really got started.

My take is that being outcomes-based means starting any process with the outcomes we want to achieve and working back from there to determine activity, not starting with the “what do we do now”.

If we want to achieve improvements in life expectancy and health inequality, we shouldn’t start an improvement process by considering small chunks of discrete areas. In an era of shrinking resources we need to consider the resources that are already in the system and whether they are contributing to the desired outcome. 
Yes of course it’s important to deliver services to individuals who have legitimate needs and whose circumstances will be improved by those interventions. From a population perspective, in any policy area I’ve ever looked at the most efficienct and equitable way to improve outcomes is through changing the risk at population level and taking an ecological approach.

Four examples – 

Diabetes – Take my precious blog on preventing diabetes and the individual by individual approach vs s societal approach. 

Preventing diabetes. Indivudal vs population based approaches – on emptying an ocean with a teaspoon. https://gregfellpublichealth.wordpress.com/2016/11/28/preventing-diabetes-comparing-service-to-policy-based-approaches-on-emptying-an-ocean-with-a-teaspoon/

Air quality – we will obviously focus our attention on regulating high risk polluter vehicles, we may well miss the point if we don’t also focus on population level modal transport shift.

 cancer – if I care about breast cancer survival then I’m going to sweat a lot about effective treatment coverage (NB not screening!), if I care about breast cancer mortality I’m going to sweat a lot about breast cancer incidence- as reduction incidence is a sure good way to reduce mortality –  and the risk factors for that – obesity related cancer being a major worry.  Similarly lung cancer – treatment coverage vs incidence and risk factor reduction. If you really want to focus on outcomes think about it really carefully.

Stroke – If we want improve stroke outcomes we can either make improvements to the stroke pathway – often these are pretty marginal and don’t make massive differences to  the outcome, or we can think about preventing  stroke at population scale and making improvements to the pathway also.  Blood pressure and salt in diet anyone.

So next time you hear they want to be an outcome based commissioner, or an outcome based this or that….ask them what outcome, what population and what interventions.

In an area close to my heart, health and health care the macro implication of all this is to change the nature of commisisoning. Move from being a commissioner of health care, to a commissioner of health. 

That would change the nature of the game

Why don’t we get this? Probably a combination of ideology, deeply held beliefs, long history of individualistic approach, territory and resource base to defend in keeping status quo.

We all want to be outcomes based, we often say we are, but then go and carry on doing things that may not actually a acheive the outcome we want to
#just saying