Within physical sciences, one of the key considerations in developing theories or carrying out experiments is the observer effect. This is where the act of observing something changes the very thing you are observing. For example, in electronics, the act of using a voltmeter changes the voltage in a circuit.
I want to suggest that there is a similar tension in measuring outcomes in the provision of health and wellbeing services. All too often we invest significant time and effort in pre-determining the outcomes we want to achieve and then modelling the measurement in a way that will best return those outcomes. This creates a problem in that it is utterly reductionist.
Most services exist in relatively complex environments sitting next to, and being reliant on, other services that live in a supply chain. Changes in any of those services are likely to have a knock-on impact on the outputs of the whole system. Given the nature of how funding flows around the health and care system, it’s quite possible that services that have developed a symbiotic relationship don’t share the same stated outcomes.
The decision to reduce measurement to a narrow range of outcomes creates a number of problems for agencies. It frequently means that collateral benefits are missed. A service that is hypothecated to deliver one outcome might, in reality, produce an entirely different benefit that provides a similar level social value. If the measurement systems are too simplistic this additional benefit might be lost, and an otherwise productive service be condemned to be decommissioned.
Similarly, as we better recognise that people present complex issues we need services to work together around an individual. This raises the ever-present problem of attribution. When services work together with an individual how do you attribute outcomes? Can you draw an incontrovertible line of causality between one agency’s intervention and an outcome?
Narrowly defined outcomes impact on services because they can undermine the core purpose of an organisation. As more and more services are commissioned from the voluntary and community sector there should be a challenge to which has precedence, the social objectives of an organisation or the perceived impact of a contract? If the operation of an individual contract begins to distort the reasons for an organisation’s existence then that organisation will not be sustainable in the long run. We are seeing a developing problem in recruiting trustees for organisations and in most cases, it is the social objective that buys this voluntary effort.
A significant problem is how we interpret the commissioning of services in terms of normal purchasing. If I want my plane to fly, then I need to buy at least two wings. If the wings don’t hold the plane in the air, then there is a clear contractual failure. We can’t apply a similarly binary approach to community services. You cannot go to an agency and purchase a 10% reduction in GP attendances. The factors that influence whether people go to see a GP range from general improvements in health to not being able to get an appointment. Many of those factors are completely removed from an individual service’s influence.
The solution to this is to be more creative in developing services and contracts. By all means, set a headline objective for a service but configure reporting to capture the broad range of outcomes that result. In most cases, those outcomes will act as proxies to indicate whether the headline objective has been met or not.
Although that sounds theoretical it is relatively easy to achieve. From a contract management point of view be open to all the outcomes that are achieved by a service. Most services are fully aware of the impact they have on a range of areas and are frustrated that they often don’t get to tell that story.
If you’re managing a contract, when you become aware of collateral benefits, reach out to other agencies. Your day job might be defined by a marginal change in A&E attendances but it’s a complex world and you might be looking at an answer to someone else’s thorny problem. After all, it’s all public money.
Contracts and contract management are essential to ensure the efficient allocation of resources. The act of observing those contacts should be a check on value for money but should not dictate how the service is delivered.