Health Improvement Performance Management Review:

Supporting Outcome-Based Approaches to Planning and Performance

Neil Craig & Tamara MulherinPolicy Evaluation and Appraisal

NHS Health Scotland

Outline

• Why a review?• How is the ‘performance landscape’ changing?• Threats or opportunities?• Outcomes ‘tools’:

- that may help make the most of the opportunities

Why a review?NHS performance management • dissatisfaction with Health Improvement (HI) section (the ‘H’ bit) of

the HEAT targets.

Barriers to effective performance management for HI• Too many health improvement priorities• Inter-sectoral, partnership-based delivery – all too complex, knowing

who did what and their impact difficult to determine, varied accountability requirements

• Performance targets for HI lay with one sector (NHS) • NHS targets were unspecific to delivery and beyond direct control of

NHS• Uncertainty about effective actions

Main aims of the Review• Specify more clearly the unique contributions of

specific sectors to delivering HI (including health inequalities) and the contributions which need to be delivered in partnership

• Develop PM arrangements for shared HI outcomes in a multi-level, cross-sector, partnership-based delivery system

How is the performance landscape changing?

SOAs: Guidance for 2009/10

• SOAs are the “means by which CPPs agree their strategic priorities for their local area and express those as outcomes to be delivered by partners, … while showing how they contribute to the Scottish Gov’t’s relevant National Outcomes”

• The SOA “must be a strategic document … underpinned by robust performance management arrangements… [and] a very clear line of sight from the SOA document.”

SOAs: AccountabilityLetter from SG to Chief Execs

Signing up to an SOA means that partners:• “are corporately committed to the agreed outcomes …

and … will take every opportunity to promote and support the achievement of outcomes.”

• “doing this is likely to include each partner looking at how they individually can contribute to outcomes” and

• “each partner will need to show that a ‘golden thread’ runs from the SOA through their planning, resourcing and performance management processes.”

Threats?• Top-down priorities?• If outcomes are uncertain, might funding be cut?• Partners or competitors?• End of ring-fenced funding?

Opportunities• To contribute to setting local priorities• To show the contribution that partners, including 3rd

sector organisations, could make to improving health• To show the contribution that partners, including 3rd

sector organisations, do make to improving health

Outcomes ‘tools’• What do you currently do?• Who do you hope to reach?• What would you love to see?• What would you like to see?• What would you expect to see?

Well-being

Population health

Health inequalities

Individual behaviours and capabilities to achieve behaviour change

Social, economic, and physical environments e.g. social capital

What would you love to see?

What would you like to see?

What can you expect

to see?

Outputs: e.g. no. of people involved, no. of mtgs held

Inputs: e.g. community workers, land, co-producers’ time

Processes: e.g. partnership working, advocacy

Performance management

Public ReportingNational Performance

Framework

Outcomes related to service delivery e.g. increased self-esteem

What do you want to see & how can you (help to) do it?

What do you do?

Outcomes Triangle – Physical Activity (PA)

GreenerSafer & StrongerHealthierSmarterWealthier & Fairer

Increased physical activity levels

LONG-TERM

HIGH LEVEL OUTCOMES

INTERMEDIATEOUTCOMES

SHORT-TERM OUTCOMES

Outcomes related to service delivery

Increased availability and affordability of leisure

facilities

NATIONAL OUTCOMES

Our children have the

best start in life

Improved child

development

Reduced deaths from CHDImproved mental well-being

Reduced illnesses due to obesity

Reduced inequalities in healthy life expectancy

We live longer, healthier lives

We have tackled the significant

inequalities in Scottish society

Built & Natural environments that encourage PA

More use of the outdoors for PA (NI)

Safer streets and roads More journeys to work/school

by active travel (NI)

We create well-designed,

sustainable places

We value and protect the natural environment and

cut our environmental impact

ProcessesOutputs

Inputs

INTERMEDIATE OUTCOMES

Linking activities to outcomes

LONG-TERM OUTCOMES

Reduced Type 2

Diabetes

Reduced CHD and

stroke

Reduced cancer

NATIONALOUTCOMES

Longer, healthier

lives

Tackled significant inequalities

Other non-health

outcomes?

Reduced prevalence of overweight and

obesity

Improved energy balance

Model a

Model b

Model c

Model d

Model e

Increased food industry corporate

and social responsibility

Changes in availability and affordability of

energy-dense/low energy dense

food

Improved early years nutrition

Increased individual

empowerment and food literacy

Improved media and social

environment

Increased physical activity

Physical Activity – Who might do what and why?

Inputs

Activities

Outputs

Reach

Short-term outcomes

Intermediate outcomes

High level outcomes

NHS

Assessment/ Advice in

Primary Care

No. assessed and given

brief advice

Patients at risk

Still active at 3 month follow up

Behaviour Increased physical activity levels in population

Reduced inequalities in healthy life expectancy; Reduced morbidity due to obesityReduced inequalities in CHD; Improved mental well-being.

Comm & Vol orgs

Walking clubs

Memberships of clubs

At risk groups in population

More people walking

regularly

Councils: Education

Curriculum development

Increased PE in curriculum

School age children

Increased PA in school time

Councils: Transport

Promoting active travel to

work/school

Increased cycle lanes and safe

routes to school

Commuters and school pupils

More short journeys by active travel

Councils: Planning/

Environment

Creating green space

Creation of more/better green space

General (inactive)

population

Increased use of green space

Environments Built, Road & Natural environments enhanced

to create more and safer PA opportunities

What it is & what it’s not!• Not just rationalising what you currently do

- challenging and promoting it- on the basis of evidence, logic and engagement

• Not being told what to do- contributing to debates on priority outcomes- articulating contributions to shared priority outcomes- providing a rationale for working towards and measuring particular outcomes

• Not a way of describing complex reality- a way of critically reflecting on, prioritising and accounting for what you do