The commissioning of outcomes as opposed to activity (=hours ‘delivered’) remains an elusive target. Will it ever happen? Our view is yes…but we have a long, long way to go.
The recent report by the Local Government Information Unit (LGiU) entitled ‘Outcomes Matter: Effective Commissioning in Domiciliary Care’ highlights the frustrating gap. According to their survey, over 90 per cent of commissioners regard outcome commissioning as ‘important’ or ‘very important’. At the same time over 90 per cent of commissioners acknowledge that they pay providers on time spent with service users as opposed to paying for outcomes.
What is holding us back?
A number of factors are holding us back. Firstly, commissioning outcomes is difficult. It is significantly easier to agree a rate per hour, maybe install call monitoring to track actual hours delivered, and then tinker with market forces when contracts are re-tendered. Secondly, outcome commissioning requires different systems than those currently in place. In the LGiU report, over 75 per cent of respondents confirmed that current systems and processes are not sufficient to manage such changes.
Based on our experience helping both providers and commissioners of care from the private sector and the public sector, we have developed a framework that helps overcome the difficulties involved in the measurement and management of outcomes:
1: Focus more on the cohort, less on the individual
This may seem counter intuitive, but given the huge variation in circumstances at a single person level, it is impossible to design robust outcome measures solely based on individual outcomes. Take one of the most pressing needs in health and social care – the reduction in hospital admissions – it is impossible to measure a provider’s performance on an individual admissions. However, it is eminently possible to reward providers for keeping the number of hospitalisation rate per 1,000 service users below an agreed figure. By focussing on outcomes per cohort of service users, commissioners will drive providers to innovate and find better ways of delivering.
2: Low/moderate number of providers
Competition is a great thing and market forces are powerful but the idea that a huge number of providers will deliver better services makes little sense. We are not talking about selling commodities but the delivery of complex care services. A low/moderate number of providers is important for two reasons: Firstly, providers need an incentive to invest in service design and people in addition to gaining expertise in a particular sector. Secondly, a small number of providers will allow the creation of groups or cohorts that are of meaningful size so that that statistical significance of the recorded outcomes actually represent good performance and not good luck.
3: Hospitalisation Episodes & Satisfaction are the two key outcomes
Commissioning outcomes is hard. Let’s make sure we don’t make it harder. In our view, there is always the temptation to load up the outcome measurement with so much complexity that is becomes impossible to execute well. The key is to start with modest ambitions in terms of the complexity of outcomes commissioning BUT focus on good execution and compliance with those relatively simple outcomes.
We believe that going forward hospitalisation episodes and service user satisfaction will be the pillar of any outcomes commissioning. Hospital admittance is easy to track and very expensive in terms of cost. Frequent admissions are also a sign that the overall care process is not working. Satisfaction is also easy to measure and a good indication of whether the service is working. These two measurements can be augmented by a number other of outcomes frameworks (there are probably a dozen to choose from), however, this data can be much harder to collect and few local government organisations have the systems for such collection.
4: Enable choice by encouraging providers to build brands
Commissioners that are interested in outcomes should have a strong interest in developing a small/moderate number of strong and recognized providers in their commissioning system. Without a recognised brand, the idea of choice is pretty meaningless. Whether a savvy consumer or a vulnerable person supported by a carer, a brand is not a perfect shortcut, but is certainly is a familiar shortcut to a complex purchasing decision.
It is much more meaningful then for the commissioner to publish outcomes data when the public has or can develop and understanding of what a particular brand is about.
5: Providers will follow the money..
Almost all providers we speak with would endorse a move to commissioning outcomes. Today the domiciliary care market is racing to the bottom. Providers are being asked to provide the cheapest labour unit cost possible with no regard for what they achieve.
Large, committed private operators in adult services see a move to outcomes as important for their survival. They don’t want to compete exclusively on price. They want to build organisations that deliver innovation and valuable services…better outcomes at lower cost.