Mark Jeffs @markjeffs75, from the Wales Audit Office, has blogged for us ahead of our Moving from outputs to outcomes webinar on May 16. Read on to find out more about what matters, rearranging the deckchairs and evil kittens…
Everybody loves outcomes. We all want them. Well – we want good ones at least. So if we all want them, what is the problem with getting them and focusing public services on delivering them?
This blog offers some personal thoughts on these issues ahead of a webinar that the Good Practice Exchange is hosting in May.
The context – why do we need to shift from outputs to outcomes?
It is a complicated story but broadly, the mid 90s onwards saw a growth in the use of targets to manage the performance of public services. Generally, these targets were set centrally and based on measures of outputs (how much we do) and how quickly we do it.
Since then, there has been something of a backlash. Many critics argued that the targets had ‘perverse incentives’. That is, they encouraged people to do what was necessary to meet the target rather than do what was necessary to improve the lives of the people using services. Also known as ‘hitting the target but missing the point’.
Against this backdrop, the last decade has seen increasing calls for a shift towards ‘outcomes’: to focus public services on ensuring they make a real difference for people.
There is a big value for money issue at stake. Can it be ‘value’ for money if we spend a lot of money delivering outputs that don’t make people’s lives better? The true ‘value’ of public service ultimately lies in improving people’s lives. With austerity set to continue to define the public service landscape, the shift to a focus on outcomes can help to move our discussions from doing more with less to making more of a difference with less.
The opportunity: really transforming our services based on ‘what matters’
The great opportunity of shifting from ‘outputs’ to ‘outcomes’ is not about measures at all. It is about changing our thinking and the way we deliver services. To shift towards a model that starts with people, the lives they lead and the lives they want to lead. In short – real ‘people centred’ services.
There are reasons to be optimistic. The language of ‘what matters to people’ is increasingly common in public service. Not least in the context of Wales’ approach to social services which is based around the notion of personal outcomes and what matters to people. More broadly, if you look here in Wales at legislation such as the Social Services and Well-being Act and the Well-being of Future Generations Act, alongside a range of policy documents on public service reform, a new vision of more personalised, user-focused public services is emerging. It involves:
- Rethinking the relationship between frontline staff and service users (co-production) to focus on improving people’s lives
- Reshaping the relationships between services / departments (real collaboration around people to give holistic support)
- Developing the management/ leadership thinking to see the role as enabling the learning and change needed to improve lives, rather than monitoring numbers/ performance
The issue of what outcomes to measure is secondary to the underlying behaviour, cultural and systemic shifts implied by this vision. If we start with understanding what matters, we can then work out how collectively we can organise ourselves (as public services working with individuals and communities) to help people achieve the things that matter to them. From there, we can identify ‘outcomes’ measures that are rooted in the lived experience of people’s lives, rather than abstract idealised imagined conditions of wellbeing.
That is not to say that this is easy. There is a big technical challenge around how you measure personal outcomes and make them consistent and meaningful at different levels (service/ organisation/ nation). By their nature, personal outcomes are . . . personal. They are different and inconsistent. I worked on the Auditor General’s Picture of Public Services 2015 report. In that report we flagged the approach developed by the Scottish Joint Improvement Agency: a framework for linking personal outcomes through consistent categories that are tailored to individual circumstances. The Joint Improvement Agency gives examples of how these can be aggregated through different levels from the individual to national outcomes.
The risk: superficial changes (or rearranging the deckchairs)
There is a risk that public services respond to the pressure to focus on outcomes by doing the bare minimum. The simple way to shift to outcomes is for public sector leaders to replace existing output targets and measures with a new set that uses more ‘outcomey’ language.
There are many reasons to be sceptical about an approach that is essentially the result of a discussion about measurement amongst a relatively small group of senior leaders. The questions I would pose to those adopting such an approach are:
- What is the evidence that these are the right outcome measures – how do you know they really reflect the things that matter to service users and to the wider public?
- What are the links between new measures and the plans to change the real experience of providing and receiving services?
For me, the biggest risk of this approach is that it does not lead to the kinds of changes we need to see. Instead, we get superficial changes. The new outcome measures form part of a new ‘strategy’. There will be a new overarching delivery plan, departmental action plans and underpinning service delivery plans. Frontline staff may look at all of this paper once (at most) and then get on with the business of providing services much as they always did.
The other big risk is that changing from numerical output targets to numerical outcome targets risks creating the same perverse incentives and behaviours. Instead of chasing outputs, service providers chase numerical outcomes with unintended consequences. This concern is articulated in Toby Lowe’s ‘kittens are evil’ critique.
The baby and the bathwater
It is essential to emphasise that the shift from outputs to outcomes is one of emphasis. There should be no sense that output, activity and timeliness measure no longer matter. They do. They are vital for understanding demand and capacity and planning the delivery of services and systems. Nobody could argue that we should stop measuring and caring about how many people come into and out of hospitals and how long they wait for treatment. The issue is how much emphasis we place on these measures and how much they should drive behaviours.
So what are the key messages on shifting from outputs to outcomes:
- The shift to outcomes is about so much more than measures and indicators – it is a different way of seeing and providing public services that starts with people’s lives and what matters to them in their lives.
- As well as service delivery, shifting to outcomes means a shift in the role of management as enabling and leading practical changes rather than monitoring numbers and chasing targets.
- When it comes to measures, the idea of a shift ‘from’ outputs to ‘outcomes’ may miss the point – it is about the right balance of information to understand both what is happening in the system and how well the system is doing at making the lives of people and communities better.