Developing a stronger focus on outcomes in health and social care has been anobjective of the Department of Health and various institutions and academicbodies for at least the last 20 years. This quest for an effective outcome-basedapproach to commissioning and providing services was underlined again by theWhite Paper, Equity and Excellence: Liberating the NHS(Department of Health, 2010a) and associated working papers, notably theconsultation on outcomes led commissioning, the NHS Outcomes Framework2011–12 (Department of Health, 2011c), and the consultationpaper Healthy Lives, Healthy People: transparency in outcomes(Department of Health, 2011a, 2011b).

While an emphasis on outcomes is both timely and welcome the consultation papershave demonstrated once again the difficulties associated with identifyingoutcomes that are sufficiently robust to be used as contract currency. We takeas axiomatic that a greater emphasis on outcomes is desirable and achievable,but recognise that implementing a truly outcomes focused approach will beenormously difficult for a number of reasons.

In a seminal paper, Donabedian (1988) demonstrated that quality in health carerequires a proper integration of structural features (such as input resourcesand outputs achieved), processes related to offering care, and the outcomes ofthat care. He emphasised the importance of balance: every outcome has some formof supporting process which in turn requires a set of inputs. Focusing onoutcomes to the detriment of inputs will not achieve the goal of improvingoutcomes; conversely placing undue weight on structural features (inputs oroutputs) will not realise the best outcomes.