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Analysis: A huge change in the nature of the NHS

The old system of measurement and reward based on activity has never sat easily with clinicians – especially within primary care.

Tariffs that were based on achieving certain targets – such as avoiding four-hour waits in A&E departments – were understandable, but often did not reflect what the patient themselves wanted.

They were also open to potential ‘gaming', with a possible increase in short-stay hospital admissions occurring based on the need to avoid a four-hour target breach rather than true clinical need.

So for years clinicians have asked to be measured on things that mattered more to them and their patients, and the Commissioning Outcomes Framework starts us down that journey.

It is difficult to come up with perfect outcome frameworks, but the direction is correct. We will all agree it better to have our system orientated at rewarding the achievement of independence by a patient three months after a stroke, for example, than simply because somebody managed to be in a particular type of hospital ward for 90% of their time.

However, there are so many variables that influence that outcome – such as severity of stroke, presence of co-morbidities and home circumstances, to name a few – that it can be seen to be difficult to come up with the perfect measure.

Some of these outcomes will be challenging. Influencing the under-75 year old mortality from COPD will take some time to achieve. It is less instant than adjusting medication to achieve a better peak-flow rate. But it does make more sense that, as commissioners and providers, we work towards that outcome instead of just adjusting a single measurement.

Some will be difficult. Improving satisfaction with GP out-of-hours services appears to be out of the individual clinician's immediate remit. But as the new commissioners, we have taken on the responsibility of ensuring that the overall care of our patients is the best possible. And if it is not satisfactory, we need to get our CCGs to change things.

The other notable feature is that a lot of the outcomes can only be achieved through population-based care. Influencing admissions for alcohol-related disease will be achieved only in co-operation with local authorities, public health and the voluntary sector. It will also depend on integration and working together without an enforced primary-secondary care divide.

For the individual GP, the COF presents an opportunity to see the measurements used in health management becoming more closely aligned with day-to-day experiences.

It also represents a huge change from being a reactive service being delivered for an individual patient into a proactive service given to an individual in the context of their overall community.

Dr Donal Hynes is co-vice chair of the NHS Alliance and a GP in Somerset