Connect Health’s Danielle Chulan discusses how healthcare services and patient care can be improved if commissioners link performance measures to quality and high value activity.
According to Danielle Chulan, Deputy Director NHS Services at community services healthcare provider Connect Health, target-setting can stifle innovation; and an obsession with quantitative measures – such as how quickly a letter is sent or an appointment is made – steals focus from the core need for value in healthcare. Chulan makes the case to modernise measurement.
Target-setting is contentious and a national problem. At Connect Health, we are committed to demonstrating that we’ve made a significant impact on patient outcomes – but how can you demonstrate that impact when the key performance indicators (KPIs) used to track performance focus primarily on process?
What is the purpose?
“Is performance driving your purpose or is your purpose driving your performance?”
This question was posed to me in a coaching session and it stopped me in my tracks. A good friend of mine, Tony Anagor, taught me to unpick questions and understand the question before the question. In this instance the real question is ‘what is your purpose?’
NHS-commissioned services usually measure performance based on a set of KPIs and the purpose of most commissioned services is to provide system-wide value. I quickly had to accept that within NHS-commissioned services there is huge focus on performance driving purpose, rather than the other way around.
The challenge is to ask yourself: why are you measuring something that does not evidence or contribute to your purpose? As a data analysis enthusiast, this triggered some deep thought around how KPI measurement within NHS healthcare services often fails to measure what impact we are expecting to achieve as a service.
I began to look at how targets link to behavioural change, and came across a blog: ‘Campbell’s law and why outcome measurement is a dead cobra’. Campbell’s Law suggests that people change their behaviour to achieve targets that are being used to measure their performance. Sound familiar?
NHS service level KPIs and financial remuneration tend to focus on how quickly a process is completed and how many patients have been seen, rather than linking efficiency to improved patient outcomes. This is quite remarkable when you think about how Campbell’s Law indicates that targets indirectly and unconsciously influence behaviour. This sometimes leads to the achievement of KPIs directing what we do and the decisions we make – over and above driving our purpose.
Stop the spuddling!
An example of this relates to an access KPI. The achievement of this KPI drives our decisions to ensure that patients are seen within a targeted time. This results in us spending a lot of time ‘spuddling’ (Sam Riley, NHSE), or making a lot of fuss about trivial things as if they were important.
Quick access to healthcare is an obvious necessity – but should we be running around with our hair on fire trying to manage variable demand in an effort to ensure 90% of patients are seen in 20 working days and not 23 days; and crucially, what difference does that even make?
If our purpose is to see as many people as quickly as possible then process-based measures are perfect. However, if our purpose is to improve patient outcomes and experience, and to empower and enable patients to improve their quality of lives, where do these measures sit in the pecking order of value measurement? And how could they be influencing behaviour?
A service may deliver a high volume of appointments very quickly with the funding allocated to it, but if those appointments do not equate to improved health outcomes for patients, the service is not improving the quality of the lives of those it serves.
If process and activity management (payment on results) is replaced by quality and outcome management (value-based commissioning), the purpose can drive the performance. This delivers multi-stakeholder satisfaction for patients, taxpayers and clinicians, simply because what gets measured gets done.
It is also worth recognising that placing emphasis on activity and process commissioning can stifle innovation. Rigidly linking activity plans and process management to financial arrangements, such as activity-based contracts, encourages greater focus on quantity over quality. This can result in perverse incentives, limiting high value care and efficiencies that innovation and digital solutions can bring.
We have seen rapid innovation in services during the COVID-19 pandemic, coupled with light touch contractual performance management and protected income for NHS services regardless of indicative activity – this is no coincidence.
A case in point: Nottingham
Nottingham is a good example that demonstrates how a new approach has yielded tangible results.
Nottingham North and East and Nottingham West CCG commissioned an integrated musculoskeletal (MSK) community service in 2016, with metrics around quality at the heart of its KPIs. The purpose of the service is to help patients achieve a better quality of life and reduce inappropriate referrals for invasive and expensive joint replacements. Our data shows that between 2016 and 2019:
- Based on patient pathway data from in-house clinics, surgical conversion rates significantly improved from 30% to 90% from Year 1 to Year 3;
- 30% less patients were referred to secondary care in Year 2 as compared to Year 1;
- £2.6m was saved annually, based on 2018 figures;
- DNA (Did Not Attend) rates were low, at just 4%; and
- One in four patients joined local authority gyms on completion of the Connect Health rehab programme.
Crucially, this level of improvement was maintained throughout 2019 and into 2020.
Nina Ennis, Director of Planned Care at NHS Nottingham and Nottinghamshire CCG, explains: “KPIs provide useful information on how services are performing, and whilst they should not be restrictive or cumbersome, they can highlight the need for change and support discussions about performance. Outcome measures are developed to make a real difference to our patients; and working collaboratively with all of our local MSK providers, these allow us to understand and improve the quality of our MSK services.
“Our contract approach includes local incentive schemes, which supports providers to strive for high-quality performance. This was paused in March to allow providers to concentrate on delivery of safe services, during the COVID period, with new ways of working developed by providers to meet restricted provision.”
Importantly, in addition to patient outcomes and value, we have to consider the needs of a range of stakeholders, including staff. It is no coincidence that in 2016, our Nottingham clinicians reported an overall employee satisfaction score of 46%. This increased after one year to 90% when the updated KPIs were introduced, and satisfaction is now at 95%. Staff wellbeing is part of the jigsaw, impacting directly on patient delivery.
More recently, in a conversation about service evaluation with Lincolnshire West CCG, we identified that none of the original KPI targets demonstrated what the service was commissioned to achieve. This prompted a review of the KPIs for the commissioned community pain management service.
The original KPIs were mostly process driven, in terms of how quickly a patient letter was sent to the patient’s GP, DNA rate, etc. They simply did not contribute to the purpose of the service, which was to support patients to live well and have meaningful lives, evidenced by patient reported outcomes, satisfaction and wider health system use and measures.
We have recently changed these KPIs to make them quality and value based. The result is that the focus of the operational and clinical leadership team has changed from spending lots of time understanding why patient letters were sent in three days instead of two, to investing time and energy on pathways and developments that improve the patient experience and outcomes.
Due to COVID-19, under-pressure CCGs have had the freedom to relax the monitoring of standard and quantitative KPIs, allowing them to innovate to improve patient outcomes – and this approach needs to continue. Because placing the emphasis on activity and process commissioning stifles innovation.
We can always do better; and my final plea is that we focus more on commissioning that truly evidences and underpins what the service and system are achieving, in terms of what they are commissioned to do (the purpose), not the processes that may or may not contribute to this.
So, how do we facilitate this? It may look like a block contract, informed by accurate data on demand, with a gain and risk share that recognises the achievement, or not, of the agreed objectives/purpose. This should include patient-reported experience and both outcome measures and wider system measures, such as population health. This forms the perfect foundations for innovation, digital integration and transformation.
The real difference comes where commissioners focus on quality and high value activity, and link performance measures to this.
Deputy Director, NHS Services