Should we use outcomes data to help manage general practice?

More information on selected outcomes at practice level are being made public,1 an outcomes framework for monitoring the performance of the NHS has been introduced,2 research is investigating the elements of primary care that can influence outcomes,3 and outcome measures are included in the monitoring of clinical commissioning groups.4 In monitoring and rewarding general practices, has the time come, therefore, for shifting the emphasis from the process indicators of the Quality and Outcomes Framework (QOF) to genuine measures of outcomes? In this article, we discuss whether we should aim, in partnership with patients, to develop outcomes monitoring combined with greater understanding of the role of demographic, economic, and social determinants of health. Health outcomes may be defined as a change in a patient’s health (including physical, psychological, and social health) that can be attributed to antecedent health care.5 They may be used in relation to patients with a specific condition or to entire practice populations. There are few frameworks of outcomes focused on primary care, but examples can be found.3,6–10 Drawing on these, we drew up a classification (Box 1) and distinguish between the final outcomes (mortality, adverse events, costs, satisfaction) and those intermediate outcomes that, although arising from antecedent care, go on to influence final outcomes. For example, patients’ experience of care will influence their satisfaction. Box 1. ### Summary of primary health care outcomes | | Outcome | Effect of primary carea | |:------------------------------------------------------------------------------------------------------------------------------------------------------ | ---------------------- | ----------------------- | | Outcomes | • Mortality, morbidity | Small | | • Disease episodes, for example, myocardial infarction, stroke | Moderate | | • Quality of life, change of health status | Moderate | | • Adverse incidents | Large | | • Equity: the extent to which there are differences in outcomes between different socioeconomic, ethnic and other groups, (sex, age, and the homeless) | Small | | • Patient satisfaction with care | Large | | • Costs, including costs of health care, costs to patients, and to society | Large | | • Time off work, time off school | Small | | | | Intermediate outcomes | Clinical outcomes | | | • Immunisation, cancer screening, health checks, clinical measures (BP, HbA1C, cholesterol, and BMI) | Moderate | | • Early detection of disease (numbers of people with undiagnosed conditions) | Moderate | | Health behaviours | | | • Smoking, diet, exercise, psychological behaviour. Capacity for self-management | Small to moderate | | Utilisation | | | • Admissions, use of accident and emergency departments, referrals, prescriptions, nursing services | Moderate | | Patient experience | | | • Experience of care, involvement in own care and in planning services | Large | | Practitioner-related outcomes | | | • Satisfaction with work, role, relationship with patients | Large |