Establishment of UK clearing house for assessing health services outcomes.

Accepted for publication 9 March 1992 The organisation and planning of health service delivery has long been dominated by concerns other than the evaluation of health services outcomes. The thrust of the Griffiths' inquiry into the management of the NHS,l resulting in the 1984 reforms, was towards the achievement of greater accountability. The then Department of Health and Social Security promulgated a set of performance indicators whose predominant focus lay in resource input and cost and in the process of care, with only five indicators relating to outcome. However, the purchaser-provider split introduced from 1 April 1991, the contracting process and associated developments such as health needs assessment, together with the emphasis on health gain introduced in The Health of the Nation2 have pushed the assessment of health services outcomes to the centre stage of the NHS. At the same time medical audit (and more broadly clinical audit) is being widely championed,3 encouraging greater awareness and focus on evaluating the process and, potentially, the outcome of care. The prospect beckons wherein purchasers, having assessed the health needs of their population, specify health (services) outcomes within contracts, thus cajoling providers to collect data on health services outcomes, although practitioners in primary health care are perhaps better placed to assess longer term outcome.4 Notwithstanding, it must be remembered that decision making in the organisation and planning of health services delivery is still strongly influenced by concerns other than the proved effect on a patient's health status. Talking about health services outcomes has become topical, but progress towards measuring and using outcomes will not be straightforward. Despite the ultimate goal of the NHS of improving the health of patients it is still difficult to measure health services outcome. Indeed, there is no agreed taxonomy. This is partly due to an underdeveloped theoretical framework and a paucity of people equipped to develop, apply, and interpret outcome measures. There is potential for a rush to apply outcome measures without a critical appraisal of, for example, the dimension of outcome being measured, their underlying validity, their sensitivity to change over time, and their reliability. In addition, there are many "available" outcome measures, and potential users are often confused as to the relative merits of each and their relevance to local issues. There is also a lack of communication between clinicians, managers, planners, and researchers leading to duplication of effort, gaps in knowledge, and little dissemination to those interested parties in the wider health and social care community. Finally, and more fundamentally, there is the question of attribution that is, is this measure really assessing outcome due to the health care intervention?