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Let’s go on a journey – new ways of dealing with complexity

Wednesday 17th February 2021

Neil Stevenson explores outcomes as a tool to support system accountability and performance in this second part of his series. You can read the first blog below:

Ghosts of Future Past – new approaches in contracting and commissioning Part 1/3

It’s the staple of Saturday evening TV, the thread that underpins Strictly Celebratory Bake X Factor On Ice – the journey. It’s not so much the destination but the journey they’ve been on that’s key: learning, overcoming challenges and believing in self. The LTP has invited us on a journey and there is focus on the outcomes that we are to deliver through collaboration and cooperation. There’s a risk though that the focus on outcomes may mean we miss the journey.

One of the underpinning issues to be resolved is the wider requirements around new system accountability. How should it operate? How should it be measured? How do we do the comparison to determine who is better or worse?  Because, of course, points mean prizes.

From a financial performance perspective over the past 30 years there has been a trend to directly tie funding to outcomes. However there is growing evidence that this approach is potentially deleterious to what is being sort. But that doesn’t mean outcomes should be binned; they are undoubtedly a useful mechanism to support decision making, focus thinking and support partnership working. But what are outcomes?

Interestingly, outside of the dictionary, there is no formal definition for what an outcome is. That’s not to say there is a shortage of outcome frameworks, both nationally and internationally. Take any disease, issue or perspective and somewhere there will be an outcome framework for it. This highlights two things, firstly an issue around perspective and secondly one of approach

  1. What’s your perspective: One of the issues with any outcome is the point of view. Is it patient, clinician, service or the organisation? Though there’s commonality there are also differences and they in turn inform the outcome and potentially how it is used. Linked to this is aggregation. All outcomes in the end (or perhaps at the beginning) are person centred. To take a disease, organisation, system (or even an individual clinician’s practice) requires aggregation and there the perception of the outcome changes. Years of sitting on panels considering requests for access to a procedure deemed of ‘limited clinical value’ highlights this. There was always a case for why a person should have the intervention even though the ‘norm’ was that the procedure would not be beneficial.


  1. What’s the approach? This is where we get to the time-honoured and hoary debate of process versus outcome measure. Too often outcomes are seen as longer term, so we look for process measures to assure us of progress or to use them as proxy measures (which then get embroiled in issues around accountability). There’s no easy solution to this (nor the issue of perspective) but looking at how outcomes are developed and then used, can help.

Crudely speaking there are two approaches to the development and use of outcomes:

  • Causality or logic models and
  • Relationship or networked models.

Traditionally, we like causality because it’s logical. It’s a neat equation:

  • Need + need + process + output = Outcome

It is simple, plot the need, design the interventions and define the outputs to deliver the outcomes required over time. It assumes causality, i.e. a direct relationship where action adds to action. Each element can be measured and/or have indicators to show progress, with the implication that process measures provide good evidence of progress. This provides a ‘line of sight’ meaning that if anything does not align with the outcome it can be easily addressed. It is also simple to assign incentives either to the outcomes themselves or the processes, that build to the end results.

There’s a problem though, and the problem is its simplicity. The simple aggregation approach leaves little room for complexity, i.e. the elements that are not controllable, the factors that sit with others that may influence outcomes.

There’s a brilliant population/public health map that looks like an explosion in a spaghetti factory.  It’s a systems map assessing factors in tackling obesity (how to tackle obesity). There are some 114 factors identified, four or five of which are directly attributable health, the rest cover issues around societal influence, individual and collective drivers, food production. It highlights how complicated it is to address obesity. You need actions within and across different sections and much like the fairground game of Bash the Mole, there’s always the risk that you ‘resolve’ one issue and another pops up.

In such a world mapping direct causality is impossible and there is no line of sight. Rather what is needed is a networked (or relationship based) approach. In this model, there’s recognition that outcomes are achieved through range of integrated activity that collectively contributes to progress. It requires a partnership and an understanding that not all elements are (directly) controllable. At a population level the approach identifies outcomes tracking progress using an evolving set of indicators, moving the health system away from tracking of inputs and aligning resource of the wider system to patient rather than provider outcomes.

Here, working to deliver outcomes is not a process that needs to be incentivised or penalised. Rather outcomes are a tool to support decision making across a partnership, a way of maintaining focus and direct or support action to shift that direction. A key part of this is at individual (patient/client/practitioner) level or collectively is a need to learn, change and adapt to the changing factors.

The LTP set out a renewed challenge: to focus on population health in a way that we’ve not done before. To do so on the basis of pursing simple logic models won’t get us there, rather we need to embrace the complexity and recognise we need to deliver through networked relationships.  Outcomes are a sign post, a tool in that process. As tennis ace and campaigner Arthur Ashe observed: ‘Success is a journey not a destination. The doing is often more important than the outcome.’