Moving from commissioning for volume and price to commissioning for quality and outcomes, with payment linked to work done, is a vision of the Commissioning framework for health and wellbeing. Yet there is still much confusion between outcomes, outputs and inputs, and few practical mainstream examples of how health and wellbeing agencies can purchase services based on an outcomes approach.

Outcome-based commissioning (ObC) focuses not on activities and processes, but on results. The key point is shifting thinking from how a service operates - what it does - to the good that it accomplishes - what it achieves. Conventional health and wellbeing commissioning and contracting have been preoccupied with activity; how many contracts with patients/service users, waiting times met, complaints received, hours open etc. Although many of these indicators are important, they do not answer the most meaningful question of all: 'what do you achieve for your patients/service users?'. Outcomes are perceived as harder to measure and monitor in some areas of health and wellbeing so the reaction is to tighten up on compliance with processes and regulations to reassure us that the service will perform. The problem with the continued emphasis on inputs, processes, and outputs is that outcomes are relegated to an afterthought - if thought about at all.

What is an outcome?

In health and wellbeing, the starting point is that outcomes are the results of support activity or interventions, not the activity itself. An outcome of a service for an individual can be described as:

“the impact or effect on the person concerned as a result of help received”

Commissioners seek to help patients/service users to achieve planned and positive outcomes e.g. a reduction in alcohol use. The outcomes planned for different people served by health and wellbeing services will be different. In broad terms they will either be: maintenance outcomes (e.g. to enable someone to continue living at home despite failing health), or change outcomes (e.g. where people experience improvements in the quality of their life that leads to greater community involvement and/or less dependency on services).

Outcomes can be further categorised into:

• Individual outcomes e.g. Keith now gets up in the mornings without staff support.
• Service level outcomes e.g. the service supported 10 service users to access the correct benefits.
• Strategic outcomes e.g. more people will be helped to live at home.

In addition, regardless of what type of outcome, it makes sense to group similar outcomes together that relate to a particular aspect of a person’s life. This is usually referred to as domains of outcomes. There are various different domains of outcomes. The DCLG published an outcomes framework for Supporting People, DfES developed five outcomes for Every Child Matters, and there are seven outcome domains in the White Paper Our health, our care, our say.

It is important to be able to distinguish outcomes from outputs (or activity), inputs and processes. From a commissioning point of view:

• Outputs are the desired level of service from the provider, which are usually expressed in terms of service availability, speed, delivery or quality. For example, the number of sessions held, the vacancy rate of a service, or waiting times.
• Inputs are resources invested into the service to deliver the outputs. For example, numbers of staff employed.
• Processes are ways of working. For example, an equal opportunities policy is in place, or all staff are CRB checked.

North West case studies

• Lancashire County Council and Care UK, a national domiciliary care provider, are undertaking an outcome-based domiciliary care pilot project for around 30 older people. It is hoped that by moving towards an outcome-based approach, flexible, personalised services, which give service users real choice and control, can be provided. Find out more about Lancashire's outcome-based care pilot project.

Sources of further help - external links

Adult social care outcomes tool kit (ASCOT) Developed by the Personal Social Services Research Unit is a new and important tool kit that enables commissioners to actively measure the benefits of social care interventions in terms of the individual’s quality of life. This can measured by eight domains; accommodation, cleanliness and comfort, control over daily life, dignity, food and nutrition, occupation, personal cleanliness and comfort, safety and social participation and involvement. These factors can then be weighted according to perceived importance given to them by the general public/ service user. These findings can then be considered in the context of wider cost data to establish whether a service is providing good outcomes for the amount of money invested.

The Social Care Institute of Excellence (SCIE) commissioned the Social Policy Research Unit (SPRU) at York University to review research on the outcomes valued by older people and progress in developing outcomes-focused services for older people in England in Wales: Outcomes-focused services for older people.

Results based accountability www.resultsaccountability.com publishes books and papers on the subject, usually to buy, but A guide to developing a using performance measures in results based budgeting by Mark Friedman is available to download.

Commissioning News published a technical briefing on outcome-based commissioning in December 2006 and an article about an ObC 'guru' in its April edition.

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