Measuring success in achieving outcomes
The aim of any indicator framework is to focus attention on those things that are going to make a tangible difference to the outcomes we seek. This is why the indicators must link to both the outcomes and the real flows inside the continuum of wellness and disease. Performance indicators can be developed for use at all levels. It should be possible to monitor both the overall system performance and the extent to which we are achieving specific outcomes at different tiers of the outcomes hierarchy.
Achieving system-wide change A broadly based (DHB/PHO) indicator framework whose logic directly matches the model of disease progression and the outcomes hierarchy is still under development. Any model must be adaptable The triad of the continuum of wellness and disease, the outcomes hierarchy, and performance framework, if developed with a whole systems perspective, can be robust and sustainable in concept while remaining adaptable in its application.
We need significant practical and attitudinal changes in the delivery of primary health care to positively affect outcomes. Incentives and accompanying performance indicators should be focussed on encouraging these necessary changes, not just on rewarding short-term performance.
Knowing where to direct such encouragement calls for a commitment to systemic thinking. This means an understanding or appreciation of the various healthcare activities, the degree of actual and potential community involvement, as well as the more formal institutional structures and policies relating to the whole of the disease continuum.
While currently focussed entirely on preventing and managing diabetes/CVD, this approach should adapt well to other long-term conditions (e.g. respiratory disease, depression, arthritis, cancer).
Even if causality and therefore prevention strategies may be less clear with other conditions, the life-course approach to disease helps identify where the evidence is strong and where the opportunities for intervention do exist. An outcome structure and accompanying incentives and indicators can then be developed to best pursue those opportunities.
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