‘Outcomes-based commissioning’ has become the dominant approach to commissioning services in the United Kingdom, with similar concepts such as value-based purchasing and payment by results being explored in the United States and Australia. Instead of determining the volume or exact nature of services, outcomes-based commissioning focuses on desired ‘outcomes’, such as changes, healing or other effects that take place as a result of services, allowing producers and clients to shape the way targets are reached. But what effect does commissioning for outcomes have, and is it a better way to commission services?
According to a study by Bovaird and Davies (2011) outcomes-based commissioning can be effective and innovative, but requires investment. It needs to be co-produced with people who are using or likely to use services, as effective commissioning cannot be reached in isolation. Bovaird and Loeffler (2013) and Sanna Tuurnas (2016) argue that co-production improves the achievement of client, service and public outcomes.
Commissioners can also have a strategic role in leading, influencing and coordinating partners, enabling a whole systems approach that drives change. In outcomes-based commissioning it is unlikely that a single provider could deliver any given outcome on their own. Focussing on outcomes can deliver greater value and cost reduction as a by-product, allowing reflection on service quality and practice.
Reducing costs of delivering services without measuring outcomes could also be disastrous. If there are no outcome measures one could accidentally decommission vital services affecting the well-being of clients.
However, evidence for improvements linked to outcomes-based commissioning is limited and hard to find, as are studies showing that outcomes-based commissioning is better than traditional methods. In addition outcomes-based commissioning is not an easy approach to apply. There are difficulties in establishing links between interventions and outcomes, with a tendency to focus on inputs, outputs and processes instead, which tell us little about real change.
Yet although measuring outcomes is harder than measuring outputs, it is possible. Evaluation can be undertaken jointly by the commissioner producer and clients, building on two questions: how has the service made a difference, and how are the lives of the clients better as a result? Commissioning can also lead to unintended effects, so evaluation should articulate not only the outcomes, but also the way change occurs.
The Outcomes Star, is a tool first published in 2006 to measure change and gather data on outcomes achieved, building upon indicators of sustainable impact. The Star sees clients as co-producers and is based on a Theory of Change approach. Meanwhile Outcomes Based Healthcare OBH works with three types of measures which each implies a different set of data issues: Clinical and Social Outcome Measures (CSOMs), Patient Reported Outcome Measures (PROMs) and Patient Defined Outcome Measures (PDOMs). However data collection is a point of concern: CSOMs have more consistent data collection processes than PROMs and PDOMs.
There are also several different outcome banks and indicator banks, like ASCOT and SROI (social return on investment), although these also encounter difficulties in defining and measuring outcomes. A key challenge identified by Harlock’s (2014) research was the depth of data required to demonstrate social value, and the individualised nature of the data. Finding standard indicators and measures for outcomes is difficult because they may be unique to individuals or services.
In defining and choosing outcome indicators one can also come across the question of data availability. Despite growing numbers of data systems, we do not seem to be able to utilise all the data we are gathering. For example, information may be fragmented, seldom available, not match with one’s needs, expensive or present difficulties with privacy issues.
In conclusion, there is little research on the effects of outcomes-based commissioning as a whole, and measuring links between services and outcomes still seems to be cumbersome. However, this is likely to change as outcomes-based commissioning and measuring outcomes evolve and spread into new countries, such as Finland.
Anniina Tirronen is a Doctoral Student at the School of Management at the University of Tampere, Finland. She attended the INLOGOV’s course on Strategic Commissioning in March and April 2016.