Many thanks. The title was HIPM Review, but the Review itself has evolved since early 2007. It has been shaped by the development of the NPF and the emphasis the framework places on partnership working and outcomes-based approaches to planning and performance. So the project is no longer just about performance management. It has also moved beyond an initial phase when it focused on changes to the HEAT targets that drive PM in the NHS, to look at outcomes that result from the actions of different sectors, often working in partnership.
So I’m going to talk you through the development of the review and the point it’s now reached. I’ll recap on Why a review in the first place? Very briefly describe how the system for measuring performance and accountability landscape is changing in ways which have shaped the way the Review has developed Then talk about some of the threats but also some of the opportunities offered by this changing landscape And then introduce the outcomes ‘tools’ we’ve been developing which may help make the most of these opportunities Couple of provisos: Tools and ideas aren’t new, but we think their time may have come Can’t do justice to them today – we know from past experience that they can seem too complicated to some and too simple to others. It takes time to explain where we think they fit in the current performance landscape and to clarify what they are and what they’re not. We’ll briefly try and do this at the end of the talk today, but with the proviso about the short time we have available.
The initial focus was on HEAT because of the difficulties with the system for perf man of HI but the aim was always to shift to a wider, cross sectoral focus and this has been given extra impetus by the NPF and in particular the SOA environment – HIPM is not just about HEAT it is a developing set of ‘utensils’ that can be used in the partnering environment.
Couple of slides about SOAs to illustrate how they have shaped the performance landscape in ways that require organisations to articulate the contribution they make to National Outcomes. 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”. So partners, through SOAs are expected to sign up to so-called strategic priorities – looking at the Menu of LOIs issues with the guidance shows that in HI, strategic priorities means outcomes such as reductions in smoking- or alcohol-related deaths, reduced suicides, increased life expectancy etc which support national outcomes such as people living longer healthier lives. BUT, the outcomes they choose should reflect local priorities, AND CPPs need to show the links between strategic outcomes and to local planning and performance management - hence the second bullet point The SOA “must be a strategic document … underpinned by robust perf. management arrangements… [and] a very clear line of sight from the SOA document .” Tools
What this means for partners whose services impact on these strategic outcomes was set out in a letter in February 2009 from the Chief Econ Advisor in SG, who is also the Chair of the Concordat Oversight Group, to Chief Execs of LAs, HBs and other partners within CPPs: “ 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.” So the key point from this introduction? The need for partners to be able to demonstrate the linkages between the outcomes of the services they provide and the higher level outcomes that partners and government are trying to achieve.
What threats might this pose to community-led health organisations? I ask this q’n because in a piece of work about the potential value to the 3 rd sector of the HIPM outputs, respondents saw their potential value but also raised some concerns that might limit their use in practice. Firstly, it would be seen as part of a system of imposing top-down priorities from central govt at odds with the ethos of community-led health. But the National Outcomes are so broad that along with the element of local priority setting in SOAs, they leave lots of scope for local definition of priorities and how they’ll be addressed. If outcomes are uncertain, might funding be cut? But conversely, if +ve outcomes are demonstrated, funding positions might be strengthened. Partners or competitors? People and organisations that are expected to work together are competing for scarce resources. Again, this highlights the need to demonstrate value, where appropriate, of working with partners rather than against competitors End of ring-fenced funding? Yes, a threat, but one which highlights the need to demo the value of the sectors’ work
How? By realising the opportunities the new environment offers: - To contribute to setting local priorities – which obviously depends on the strenght and nature of local partnerships, outwith HIPM control - To show the contribution that partners, including 3 rd sector organisations, could make to improving health - To show the contribution that partners, including 3 rd sector organisations, do make to improving health
So developed tools which we hope can help organisations, including community-led health organisations realise these opportunities. How? By providing a way of thinking through these questions What do you currently do? Who do you hope to reach? What would you love to see for your target groups as a result of what you do? - i.e. what do you ultimately hope to achieve? What would you like to see? - so that you and others can be (reasonably) confident that your ultimate aspirations will be met? What would you expect to see? - what is it reasonable to hope for given your influence and the resources at your disposal?
The tools we’ve developed are visual ways of thinking through the answers to these questions. Outcomes triangles specify the different levels at which outcomes need to be planned and measured. What would you love to see? In our work, we’ve assumed we’d love to see improvements in high-level outcomes – the long-term changes in population health and wellbeing and health inequalities. What would you like to see so that we can be (reasonably) confident that our ultimate aspirations will be met. We’ve assumed changes in behaviours and the capabilities (such as increased self-efficacy) that enable people to change their behaviours, as well as changes in the soc/econ/phys environments that shape these, such as social capital. What can you expect to see i.e. given your influence and the resources at your disposal? Positive changes in the shorter-term outcomes related to the more immediate results of service delivery, and therefore more appropriate for PM SOA guidance makes this distinction between public reporting on strategic outcomes ‘above the waterline’ agreed by CPPs in the SOAs, and organisational PM below it, although not yet consistently understood or applied. But it represents an opportunity for 3 rd sector orgs to demo their contribution to the higher level outcomes using tools such as these.
Use the e.g. of PA, which is an important factor in a range of health issues, such as CHD, mental wellbeing or illnesses due to obesity, and non-health related higher level outcomes such as child development and environmental outcomes Populating this framework begins to illustrate how the links might be made between outcomes at different levels and between the contribution of different sectors. CLICK Health outcomes CLICK Early years outcomes CLICK Environ outcomes CLICK Econ outcomes The framework also illustrates the idea of the waterline mentioned in the SOA guidance. Above this sit the outcomes for public reporting of outcomes through e.g. SOAs, reflecting joint contributions of different partners. Below the waterline sit the of outcomes of specific services delivered by specific orgs that need to be assessed in local PM processes.
But the detail comes from logic models – this is a simplified version of one colleagues in HS are developing to support the implementation of the national obesity strategy. The work is at the stage of developing models setting out some of these routes on the basis of evidence and other sources of info. Lots of potential activities in Models a-e where the 3rd sector might contribute: Building empowerment and food literacy through interventions to develop the social environment – model a Breast feeding initiatives and other infant nutrition projects Projects to promote PA e.g through walking clubs, through gardening initiatives, etc, with outcomes that go much wider than PA and wider than health. The models we’re developing may be of interest: As sources of info on what works As examples of how to go about linking services to longer term outcome, which local players might find useful in local planning and perf management processes
But LMs can be complicated, so we’ve tried to simplify and capture this idea of different partners making specific contributions to shared outcomes in SOAs in what we’ve called Multiple Results Chains. These can be used to summarise the key activities of different sectors and how they lead to shared intermediate and high level outcomes that sit above the so-called waterline – dotted blue line. They might help to demonstrate how the activities of different sectors align with shared higher level outcomes and how they align with each other across sectors or across different elements of a programme within a sector.
What the outcomes frameworks are that we’ve developed and what they are not: Not just rationalising what you currently do - challenging and promoting what you do and how it supports national and local priorities - on the basis of evidence, logic and engagement Not being told what to do – we’ve applied this logic and develop tools in a number of areas but we’re not doing this to suggest what CPPs and organisations they work with should do, either in terms of the outcomes they prioritise or how they achieve them. They’re tools for people to use, if useful, to: contributing to local debates on shared priority outcomes – there are national priorities but there is also local scope to define local priorities and negotiate how they are met 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 prioritising and accounting for what you do by simplifying a complex reality and shedding light on key areas of what can be a vague and often unclear route to improving health and the progress we have made along it
Transcript of "neil_craig_nhs_scotl.."
Health Improvement Performance Management Review: Supporting Outcome-Based Approaches to Planning and Performance Neil Craig & Tamara Mulherin Policy Evaluation and Appraisal NHS Health Scotland
Outline <ul><li>Why a review? </li></ul><ul><li>How is the ‘performance landscape’ changing? </li></ul><ul><li>Threats or opportunities? </li></ul><ul><li>Outcomes ‘tools’: - that may help make the most of the opportunities </li></ul>
Why a review? <ul><li>NHS performance management </li></ul><ul><li>dissatisfaction with Health Improvement (HI) section (the ‘H’ bit) of the HEAT targets . </li></ul><ul><li>Barriers to effective performance management for HI </li></ul><ul><li>Too many health improvement priorities </li></ul><ul><li>Inter-sectoral, partnership-based delivery – all too complex, knowing who did what and their impact difficult to determine, varied accountability requirements </li></ul><ul><li>Performance targets for HI lay with one sector (NHS) </li></ul><ul><li>NHS targets were unspecific to delivery and beyond direct control of NHS </li></ul><ul><li>Uncertainty about effective actions </li></ul>
Main aims of the Review <ul><li>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 </li></ul><ul><li>Develop PM arrangements for shared HI outcomes in a multi-level, cross-sector, partnership-based delivery system </li></ul>
How is the performance landscape changing? <ul><li>SOAs: Guidance for 2009/10 </li></ul><ul><li>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” </li></ul><ul><li>The SOA “must be a strategic document … underpinned by robust performance management arrangements… [and] a very clear line of sight from the SOA document .” </li></ul>
SOAs: Accountability Letter from SG to Chief Execs <ul><li>Signing up to an SOA means that partners: </li></ul><ul><li>“ are corporately committed to the agreed outcomes … and … will take every opportunity to promote and support the achievement of outcomes .” </li></ul><ul><li>“ doing this is likely to include each partner looking at how they individually can contribute to outcomes ” and </li></ul><ul><li>“ each partner will need to show that a ‘ golden thread ’ runs from the SOA through their planning, resourcing and performance management processes.” </li></ul>
Threats? <ul><li>Top-down priorities? </li></ul><ul><li>If outcomes are uncertain, might funding be cut? </li></ul><ul><li>Partners or competitors? </li></ul><ul><li>End of ring-fenced funding? </li></ul>
Opportunities <ul><li>To contribute to setting local priorities </li></ul><ul><li>To show the contribution that partners, including 3 rd sector organisations, could make to improving health </li></ul><ul><li>To show the contribution that partners, including 3 rd sector organisations, do make to improving health </li></ul>
Outcomes ‘tools’ <ul><li>What do you currently do? </li></ul><ul><li>Who do you hope to reach? </li></ul><ul><li>What would you love to see? </li></ul><ul><li>What would you like to see? </li></ul><ul><li>What would you expect to see? </li></ul>
What do you want to see & how can you (help to) do it? 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 Reporting National Performance Framework Outcomes related to service delivery e.g. increased self-esteem What do you do? Well-being Population health Health inequalities
Outcomes Triangle – Physical Activity (PA) Greener Safer & Stronger Healthier Smarter Wealthier & Fairer Increased physical activity levels LONG-TERM HIGH LEVEL OUTCOMES INTERMEDIATE OUTCOMES SHORT-TERM OUTCOMES Outcomes related to service delivery Increased availability and affordability of leisure facilities NATIONAL OUTCOMES Processes Outputs Inputs Our children have the best start in life Improved child development Reduced deaths from CHD Improved 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
INTERMEDIATE OUTCOMES Linking activities to outcomes LONG-TERM OUTCOMES NATIONAL OUTCOMES Longer, healthier lives Tackled significant inequalities Other non-health outcomes? Model a Model b Model c Model d Model e Reduced Type 2 Diabetes Reduced CHD and stroke Reduced cancer Reduced prevalence of overweight and obesity Improved energy balance 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? Behaviour Increased physical activity levels in population Reduced inequalities in healthy life expectancy; Reduced morbidity due to obesity Reduced inequalities in CHD; Improved mental well-being. Environments Built, Road & Natural environments enhanced to create more and safer PA opportunities 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 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
What it is & what it’s not! <ul><li>Not just rationalising what you currently do - challenging and promoting it - on the basis of evidence, logic and engagement </li></ul><ul><li>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 </li></ul><ul><li>Not a way of describing complex reality - a way of critically reflecting on, prioritising and accounting for what you do </li></ul>
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