How do we think about outcomes holistically?

Understanding what outcomes are currently being achieved in North West London is a key part of setting goals for what we can achieve in the future; however, "outcomes” is a confusing word, and there are many different angles from which to consider them. So, the first question is, what do we mean when we say outcomes?

Outcomes are the end results we aspire to achieve in North West London for individuals, their families and their carers. Broadly speaking, the outcomes that we want to achieve are our goals for integrated care delivery across North West London. These can range from broad lifestyle goals, such as increasing the number of days that individuals are able to spend at home or in their communities, to specific quality of care measures, such as the number of permanent admissions to nursing homes. Outcomes are our aspirations for the tangible improvements we will make for people who use services and therefore the reason for undertaking this programme of work. The outcomes for North West London need to be meaningful to our population and across all our providers, including health- and social-care.

As part of the Whole Systems Integrated Care programme, the Population and Outcomes working group has developed a practical outcomes selector tool for commissioners and providers to use to help them decide which outcomes they want to achieve, and which metrics they will use to with the attendant metrics. This should help providers and commissioners think about which metrics will be useful to measure integrated care. Providers and commissioners should use this tool to choose which outcomes to track and to create their outcomes dashboards. This reference tool can be found at http://healthiernorthwestlondon.nhs.uk/integrated-care

We can think about outcomes on several levels:

• On a macro level, there are the broad, overarching outcomes that we want the whole system to achieve. For example, these could include orienting services around service users, or empowering service users through the care they receive.
• On a more detailed, micro level, outcomes can also refer to the specific things we want each service user to achieve through the programme. For example, these could include things like service users get the right diagnosis, do not need to repeat their stories over and over, avoid unnecessary hospital admissions, able to walk down to the local shops.

Outcome

Outcomes are broader goals or sets of results of providing care. They are qualitative descriptions of our ambitions.

Metrics

Metrics are the measurements that we use to determine to what extent we are meeting these outcomes. They can be measured and tracked over time. For example, if we decided that we wanted to focus on good patient experience of care as an outcome, we might use metrics such as "Percentage of Patients who responded that they were satisfied with their care when surveyed.” Usually a combination of metrics is required to give a robust view of whether an outcome is being achieved.

There are many different ways to think about outcome, and many frameworks already exist across health- and social-care. It will be useful for us to step across the current boundaries and think about outcomes in an integrated way. We reviewed five national and local outcomes frameworks that are being used to measure quality. These included the Public Health Outcomes framework, the Adult Social-care Outcomes framework, the High-Quality Care for All framework, the NHS Outcomes framework and the Greenwich Integrated Care dashboard.

None of these frameworks are integrated across all settings of care that are relevant for integrated care. Therefore, there was reason to integrate the frameworks for measuring outcomes just as we are integrating care. Together with the working group, we summarised the frameworks into five domains. The most important perspective is the well-being of the person who is receiving services and as such, the first two domains, quality of life and quality of care are the most important:

• Quality of life
  • Personal and social goals
  • Prevention
• Quality of care
  • Safety
  • Effectiveness
  • Service user experience of care
• Financial sustainability
• Professional experience
• Operational performance

It is important that the outcomes that are chosen by commissioners as part of the Whole Systems Integrated Care programme align with the existing outcomes frameworks that are already used across the NHS. This includes the NHS Outcomes framework, the Adult Social-care framework and the Public Health Outcomes framework. The outcomes presented in this chapter are fully aligned with these frameworks.

At the core of the Whole Systems Integrated Care programme is the philosophy of empowering service users to lead full and active lives. There are two main dimensions in thinking about quality of life:

• Personal and social goals. These are outcomes that reflect how people are being supported within their communities, focusing on quality of life and well-being, ensuring people are getting the right information and support when they need it. This includes whether people feel actively engaged in their own care, whether their care and support help reduce and prevent social isolation, and whether they are satisfied with their quality of life, as well as whether they are achieving their personal goals. A large part of this is personalisation of care, which includes whether service users have a personal budget that they can use to make choices about how their needs are best met.
• Prevention. An important aim of this programme is a key component of quality of life – that is not how well the health and care system treats your condition but instead how well you are kept healthy. Through which to view safety, effectiveness, experience and personal and social goals. We need to think about how we can ensure that the metrics we choose not only measure services for current problems, but also measure how well we prevent avoidable issues.

Quality of care is an incredibly important aspect of outcomes, especially in a programme that is person centred. There are three main dimensions in thinking about quality of care:

• Safety. Primum non nocere – first do no harm, has been a central pillar of care delivery and Whole Systems Integrated Care is no different. As we change the way we deliver care, we need to ensure a safe environment and reduce avoidable harm.
• Effectiveness. Effectiveness of care means understanding success rates from different treatments for different conditions. Assessing this will include clinical measures such as mortality or survival rate, complications rates and measure of clinical improvement.
• Experience of care. Quality of care includes quality of caring. This means how personal care is: the compassion, dignity and respect with which service users are treated. It can only be improved by analysing and understanding service user satisfaction with their own experiences. This extends to the positive experience for patient’s carers and families.

We are trying to improve the delivery of care across North West London within an environment of ever tightening financial settlement. In order to continue to deliver the best care that we can in the future, we need to ensure that our model of care is financially sustainable. Key to the Whole Systems Integrated Care programme is to deliver better care that has a positive impact on the total health and care system cost base. This can be achieved through a combination of improved efficiency through reduction in duplication as well as reduction in demand for expensive interventions through better preventative care.

Organisational health is an important aspect of any organisation. To ensure an effective organisation, we need look after our workforce. An inspired and content workforce will not only be more effective and efficient but will elevate the organisation to one that attracts top talent, thus creating a virtuous cycle.

While we measure the "outputs” of care, such as quality of life and care as well as experience, we also need to pay attention to how well the Whole Systems Integrated Care "machinery” is working. This will often give a "leading” indication on whether we will perform well or not in achieving our other outcomes.

• What are the quality of life outcomes your organisation tries to create?
• How does the quality-of-your care lead to better quality of life?
• In order to achieve good quality of care, what do you need to be achieving from a financial, operational and professional view?