Gina Perigo (left) and Steve Callaghan outline the concept of the outcome strategic map and how it has been used within Liverpool PCT in the delivery of health outcomes


In the current economic and political climate it is becoming increasingly necessary for healthcare professionals to demonstrate the impact of health interventions and the resulting outcomes. This is particularly true in light of the coalition Government’s White Papers, Equity and excellence: liberating the NHS1 and Liberating the NHS: transparency in outcomes—a framework for the NHS.2

These documents deliver a strong message that commissioners and healthcare professionals should be reducing mortality and morbidity, increasing safety, and improving patient experience and outcomes for all.1 Furthermore, there is a commitment to move away from process targets to outcome measures that are clinically credible and evidence based. However, it is widely recognised that it is important to collect process measures as well as outcomes in order to understand and ensure that the quality and commissioning elements of a service are delivered.3

The White Paper, Equity and excellence: liberating the NHS, lays down proposals to replace the existing performance regimens with separate frameworks for outcomes that set direction for the NHS, public health, and social care. Organisations in these areas will be held to account, with local authorities and GP consortia taking responsibility for the commissioning of local services to improve population health outcomes and delivery of high-quality outcomes for patients.1

ABC approach to commissioning for outcomes

Attempts to deliver high-quality outcomes have led to the development of various approaches to support the commissioning, contracting, and management of outcomes. After reviewing a number of outcome-based models and world-class commissioning guidance,4–7 the Health Outcomes Team at Liverpool Primary Care Trust (PCT) developed a systematic approach to outcome-based commissioning: the ‘ABC approach to commissioning for outcomes’. This model was summarised in our previous article in the January issue of Guidelines in Practice.8

The ABC model is one of the first outcome-based approaches to commissioning that combines the world-class commissioning (WCC) cycle, principles of evaluation, evidence-based practice, and commissioning competencies.9 The ABC model helps to develop, define, implement, and monitor health outcome measures. Furthermore, it provides evidence to the WCC assurance panel on the methodology of Liverpool PCT in relation to the development of meaningful and measurable outcomes at both a population and patient level.9

Development of the outcome strategic map

It is essential that healthcare commissioners approach their commissioning intentions in a strategic way and engage with key stakeholders to ensure that there is a clear and shared vision of what needs to be done and who needs to do it to achieve the desired outcomes. This strategic approach can be accomplished through successful implementation of a range of actions that are rooted firmly in evidence-based practice.

As part of the ABC model, the Health Outcomes Team created the ‘outcome strategic map’ to support commissioners and other healthcare professionals develop a strategic overview of the outcomes, interventions, and stakeholders, which are required to achieve population-level health outcomes. Originally, the outcome strategic map was developed to support Liverpool PCT in providing a visual representation of the the organisation’s link between the strategic plan and the services it commissions. It also demonstrates how the PCT, in partnership with key stakeholders, would achieve the world-class commissioning outcomes developed in 2008 (e.g. increase in life expectancy, reducing alcohol-related hospital admissions).

This article discusses the outcome strategic map, how it has been used within Liverpool PCT, and how it can support future commissioning organisations (and other healthcare professionals) with the commissioning and delivery of health outcomes.

Outcome strategic map

The outcome strategic map is a framework that supports commissioners to develop a visual strategic overview based on best available evidence, illustrating how the desired outcome will be achieved and by whom. It provides a simple way to break down an outcome statement in order to identify and define the key outcomes and drivers that are believed to lead to improvements and which will achieve the desired high-level outcome.

The map also identifies measurements for each outcome thereby providing a clear focus on improvement and a method by which to monitor efforts and identify effective change. It is a live tool that should be continuously updated and evolved to reflect the health improvements required to meet the needs of the local population within the resources available.

When commissioning a disease area (e.g. cardiovascular disease) or addressing a population issue (e.g reducing health inequalities) the commissioner should consider ‘mapping’ out the five key elements that combine together to create an outcome strategic map (see Figure 1). These elements are:

  • evidence-based outcomes
  • improvement drivers
  • strategy
  • stakeholders
  • improvement opportunities.

1. Outcomes

Liverpool PCT has defined an outcome as a ‘predicted measure of change that demonstrates a valid and significant therapeutic impact following an agreed intervention.’ Interventions should be based on evidence or related to specific patient/client aims. Measures should be reliable, valid, responsive, and time specific.9 Once an outcome has been identified, it is important to ensure that the outcome statement is clear, well-defined, of a high level, and has been agreed by key stakeholders. The next step is to identify all of the causative and contributing factors that will have a direct impact on the high-level outcome; these should then be converted into short individual outcome statements (e.g. reduction in smoking during pregnancy, see Figure 2, the outcome strategic map for infant mortality).

2. Improvement drivers

Improvement drivers are interventions based on the best available evidence and quality standards (e.g. NICE guidance) that could be (or are currently) implemented. They must achieve the outcome and should be measured by a number of output and outcome measures as identified by working through the logic model.10 Some improvement drivers may impact on one or more outcomes.

3. Strategy

It is important to have a clear and shared strategic vision and that delivery plans are in place which reflect national requirements and evidence-based practice. The strategy should be implemented in agreement with stakeholders to drive improvement based on local healthcare needs.

4. Stakeholders

Stakeholders are the key people who should be involved in, and are informing commissioning (partners, public, patients/clients, and clinicians). It is important to identify which people should be engaged with and worked with collaboratively in order to agree, lead, champion, and coordinate activity in relation to assessment of need, planning, implementation, and monitoring of the improvement strategy.

5. Improvement opportunity

Improvement opportunities are areas that have been identified once the outcome strategic map has been cross referenced against all existing commissioned activity. Identifying gaps and areas for future development will not only demonstrate a strategic approach, but also allows the commissioner to consider options if the situation were to change (e.g. socially, financially, or politically).

Figure 1: Simplified outcome strategic map

Implementation of the outcome strategic map

The outcome strategic map is being widely used within Liverpool PCT as a fundamental part of its strategic planning and prioritisation of services. It:

  • assists commissioners in their decision making in relation to strategic planning and prioritisation
  • supports the implementation of improvement strategies and can be used as a way to monitor and evaluate performance and identify change
  • is being used as a precursor for pathway development particularly in relation to the Quality, Innovation, Production, and Prevention agenda.11

This process has been particularly powerful in helping to communicate the PCT’s commissioning intentions to wider stakeholders both locally and nationally in various programme areas, such as alcohol use, cancer, cardiovascular disease, smoking, and infant mortality. The outcome strategic map on reducing infant mortality was introduced in 2009 (see Figure 2).

More recently in anticipation of the public health White Paper Healthy lives healthy people,12 the outcome strategic map is being used to facilitate the development of Liverpool PCT’s Public Health Improvement Programmes. This approach will help to inform public-health commissioning once priorities and resources have been agreed.

Figure 2: Outcome strategic map for infant mortality

Summary

By building up a strategic picture (map) based on the level of need and the best available evidence, the outcome strategic map is a catalyst to not only support commissioners and healthcare professionals in commissioning, but brings them closer together to ensure that the best outcomes are achieved. Furthermore, the outcome strategic map can support future local health and well-being boards and GP commissioning organisations to commission more effectively, thereby ensuring the delivery of quality interventions at both a population and patient level and achieving positive health outcomes for all.

  1. Department of Health. Equity and excellence: liberating the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm
  2. Department of Health. Liberating the NHS: transparency in outcomes—a framework for the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Consultations/Closedconsultations/DH_117583
  3. Lilford R, Mohammed M, Spiegelhalter D, Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet 2004; 363 (9415): 1147–1154.
  4. Department of Health. World class commissioning assurance handbook year 2. London: DH, 2009. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085148
  5. Kerslake A. An approach to outcome-based commissioning and contracting. Chapter nine. In: Care Services Improvement Partnership, Health and Social Care Change Agent Team. Commissioning eBook. 2006. Available at: www.dhcarenetworks.org.uk/_library/Resources/BetterCommissioning/BetterCommissioning_advice/Chap9AKerslake.pdf
  6. Pately C, Slasberg C. Implementing outcome-based commissioning. J Care Services Management 2007; 1 (4): 353–361.
  7. Honoré P, Simoes J, Moonesinghe R et al. Applying principles for outcome-based contracting in a public health program. J Public Health Manag Pract 2004; 10 (5): 451–457.
  8. Callaghan S, Perigo G. ABC commissioning for outcomes model: can it be used for any service. Guidelines in Practice 2011; 14 (1): 27–34. Available at: https://www.guidelinesinpractice.co.uk/jan_11_callaghan_commissioning_jan11
  9. Callaghan S. 2010. Commissioning for outcomes. HSJ 2010; 29 September. Available at: www.hsj.co.uk/resource-centre/your-ideas-and-suggestions/commissioning-for-outcomes/5018512.article
  10. W. K. Kellogg Foundation. Logic model development guide. Michigan: W.K. Kellogg Foundation, 2004. Available at: ww2.wkkf.org
  11. Department of Health. The NHS quality, innovation, productivity and prevention challenge: an introduction for clinicians. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113806
  12. Department of Health. Healthy lives healthy people: our strategy for public health in England. London: DH, 2010. Available at: www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm G