Whoever becomes Lead for Domain 1 of the NHS Outcomes Framework will find themselves at the heart of political debates about the quality of the NHS as the next election approaches. In the NHS Outcomes Framework, all domains are equal, but some are clearly more equal than others. The reason for this is simple: the outcome measures in Domain 1 – preventing people from dying prematurely – are the easiest for politicians, the media and the public to engage with and understand. Death rates and premature mortality somehow mean more that length of stay or reporting of safety incidents. Domain 1 passes the Daily Mail (or even the Today programme) test whereas the others may not.
Navigating the political minefield will not be straightforward. The outcomes indicators in Domain 1 may be easier to relate to, but interpreting their significance is another matter.
Much of the power of the NHS Outcomes Framework lies in the ability to benchmark the performance of the NHS with that of other health systems. Yet international comparisons are fraught with difficulty, particularly when the comparisons reach conflicting conclusions. On many system measures, the NHS does well (for example the Commonwealth Fund always ranks the NHS highly in comparison to other systems).
On life expectancy, we are somewhere in the middle of the pack. Yet for many of the major killers we fare relatively poorly on measures such as mortality (an example is liver disease) and survival (an example is cancer).
The picture is further complicated by looking at trajectories. On liver disease, the outlook is consistently dire – our mortality rate for liver disease is still rising, whereas in other countries it is falling. But for cancer, the picture is more nuanced. Our mortality rate is falling, whereas in other countries the rate is projected to rise – England’s smoking epidemic came and peaked earlier. However, on survival, the picture is less encouraging – authoritative studies show that we lag some way behind comparable countries and have made only limited progress in closing the gap.
So there is unlikely to be something as simple as a single league table against which we can measure performance. And, because of time lags in outcomes reporting, we may not actually know how well we have done until sometime after the event.
The first challenge, therefore, will be for the Domain Lead to develop a narrative on our relative outcomes which satisfies political demands ("we are lagging behind other countries"), recognises progress ("the quality of services have improved significantly in recent years") and motivates services to do more ("simply by doing what we already know is good practice consistently, we can improve outcomes"). Of course none of these statements are contradictory, but a careful path needs to be trodden.
The second challenge will be to consider why we are not already doing better, particularly for those diseases identified as improvement areas. Here, there are likely to be some common themes. For example, there is now good evidence of a late diagnosis problem in conditions as diverse as rheumatoid arthritis, cancer, chronic obstructive pulmonary disease, hepatitis C, cardiovascular disease and for some mental health conditions. This problem damages outcomes and is probably a major explanation of disparities with other countries.
Identifying the issue is an important step forward, but addressing it is quite another challenge. The example of late diagnosis illustrates the important role that diplomatic skills will have for whoever leads this domain. Encouraging earlier diagnosis could require greater awareness (a public health issue), better identification of signs and symptoms (a primary care issue), short waiting times (a secondary care issue) and more proactive management in residential care (a social care issue). At a time when management time, budgets and clinical attention are stretched, agreeing different responsibilities for the problem, actions to address it and accountability for delivery will not be straightforward.
It will also be important to ensure coordinated action with efforts to improve outcomes in the other domains. For example, support for people with long term conditions or patient safety can both impact upon mortality, survival and life expectancy. I will return to the outcomes imperatives for the other domains in the coming weeks.
The third challenge will be to agree a level of ambition for improving outcomes. Again, diplomacy will be important here to navigate the countervailing pressures of the need to manage down expectations in a chilly financial climate and the desire to identify a big goal to focus attention and please political masters. The bigger goal the more attention (and resources from a very stretched budget) the issue will get, but the greater the pressure to deliver will be.
Some of these outcome goals already exist. For example in cancer, there is a commitment to save an additional 5,000 lives a year by the end of this Parliament (how this will be measured is more complex, but the headline goal is clear and unambiguous). Just last week, the Department of Health published plans for Chronic Obstructive Pulmonary Disease and Asthma which, if implemented, it argues could save 7,500 lives a year. Similar goals need to be developed for conditions such as cardiovascular and liver disease.
The fourth challenge will be to translate these ambitions into meaningful action, applying the reforms to deliver improvements in outcomes. For the NHS, many of the new levers (such as financial incentives) remain poorly understood and underutilised. Addressing this and enthusing commissioners and providers to make use of these instruments will be a key task. Alongside this, and recognising that many high level outcome goals will not make for particularly useful mechanisms for tracking performance and introducing improvements (due to lags in reporting or difficulties in applying them to small population sizes), the Domain Lead will need to develop proxy measures to help evaluate progress. In many circumstances, these proxies will look similar to process measures. An interesting battle will therefore need to be fought to win approval for these.
Many of the improvement areas in Domain 1 now have outcomes strategies and a cardiovascular strategy is in development. There is also a liver strategy promised (although this one makes even the Information Strategy look both rapid and timely). If fine words are to be translated into improved outcomes, it will be necessary to both draw together the common themes from these strategies and apply the disease-specific focus which has proved so beneficial to areas such as cancer and coronary heart disease.
In the context of the first mandate, all of this will need to be delivered in a phase of transition, where the old world habits are not yet a thing of the past and where the new world powers have not yet been fully turned on. Leading action on Domain 1 will be one of the most significant and high profile jobs in the new NHS. It will not, however, be a simple one.