Basing all decisions on outcomes is a key principle for commissioners, although in many settings it remains aspirational. Most people are now working towards an outcomes-based approach to commissioning and all will need to be aware that this is central to the government’s approach to public expenditure commissioning.
Outcome-based commissioning means putting in place a set of arrangements whereby a service is defined and paid for on the basis of a set of agreed outcomes. It means shifting the basis on which services are purchased and resources allocated from units of service provision (hours, days or weeks of a given activity) for pre-defined needs to what is needed to ensure that the outcomes desired by service users are met.
The development of commissioning for quality and outcomes, with payment linked to work done, was a vision of the Commissioning framework for health and wellbeing, published in 2007. The 2010 White Paper on healthcare and GP commissioning has refocused this aim, outlining how the current performance regime will be replaced by frameworks for outcomes covering the NHS, public health and social care, with local authorities given the responsibility to determine how best to secure the objectives identified. Outcome based commissioning, with an accompanying emphasis on individual choice, is now to be the focus for future social care commissioning across all relevant sectors.
The distinction between outcomes, outputs and inputs needs to be considered carefully and understood by commissioners. Outcome based commissioning (ObC) focuses not on activities and processes but on results. The point of an outcomes-based approach is to shift thinking from how a service operates (what it does) to the good that it accomplishes (what it achieves).
Conventional health and wellbeing commissioning and contracting have been preoccupied with activity, such as the number of contracts with patients or service users, whether waiting times are met, the number of complaints received and the hours services are offered for. Although many of these indicators are important, they do not answer the most meaningful question of all, which is what is achieved for service users.
Outcomes are perceived as more difficult to measure and monitor in some areas of health and wellbeing so the response may be to tighten up on compliance, with processes and regulations to ensure that a service will perform. Emphasis in some areas on inputs, processes and outputs may afford outcomes a lower priority. Recent changes and the new approach to commissioning signalled in the 2010 White Paper will continue the development of an outcomes focus in health and social care, although there will always be a need for some output and process monitoring, as they are likely to be part of the proxy measures needed to manage performance. Service users may be able to help with measuring outcomes and their role will be more central to evaluation and management in future, so systems for their contribution need to be in place.
What is an outcome?
In health and wellbeing, the starting point is that outcomes are the results of support activity or interventions, not the activity itself. An outcome of a service for an individual can be described as the impact or effect on the person concerned as a result of help received. Commissioners seek to help service users to achieve planned and positive outcomes, such as a reduction in alcohol use.
The outcomes planned for different people served by health and wellbeing services will be different. In broad terms they will fall into two categories:
- maintenance outcomes, for example to enable someone to continue living at home despite failing health;
- change outcomes, such as where people experience improvements in the quality of their life which leads to greater community involvement and/or less dependency on services.
Outcomes can be further categorised into:
- Individual outcomes - e.g. Keith now gets up in the mornings without staff support;
- Service level outcomes - e.g. the service supported 10 service users to access the correct benefits;
- Strategic outcomes - e.g. more people will be helped to live at home.
In addition, regardless of what type of outcome, it makes sense to group together similar outcomes which relate to a particular aspect of a person’s life. This is usually referred to as domains of outcomes. There are various different domains of outcomes:
- DCLG published an outcomes framework for Supporting People;
- DfES developed five outcomes for Every Child Matters
- Seven outcome domains were published in the 2006 White Paper ‘Our health, our care, our say’.
It is important to be able to distinguish outcomes from outputs (or activity), inputs and processes. From a commissioning point of view:
- Outputs are the desired level of service from the provider, which are usually expressed in terms of service availability, speed, delivery or quality. The number of sessions held, the vacancy rate of a service or waiting times are all outputs.
- Inputs are resources invested into the service to deliver the outputs. The number of staff employed by a service is an input.
- Processes are ways of working. An equal opportunities policy or CRB checks on staff are processes.