“If we can’t measure it, we can’t do it”: the role of health outcomes in community and allied health service accountability

Abstract

Health outcomes fulfill a number of roles in the health sector. Economists, clinicians, researchers and managers use health outcomes in a range of different contexts for distinct purposes. New management approaches that use contracts as the basis for health service accountability have attempted to take health outcomes from their clinical role into a management setting. In particular, the purchasers and managers of some health services expect that service providers should demonstrate that they improve the health outcomes of their patients to justify their on-going funding. However, a number of organisations have experienced barriers to the application of the outcomes approach to health service management and there has been no systematic evaluation of the approach. Nor has there been an investigation into why purchasing organisations have difficulty introducing health outcomes into purchasing contracts. The result is that managers and purchasers continue to assign resources to the pursuit of health outcomes as an accountability tool. This thesis addresses two research questions around the use of health outcomes in community and allied health service accountability. The first is the barriers to the application of health outcomes to health services accountability. The second question examines the conditions that must be met before health outcomes can be used as an accountability tool in purchasing contracts for allied health. The research questions are addressed through the analysis of case studies that explore systematically the approach taken by two organisations, the Department of Veterans’ Affairs and ACT Community Care, in their attempts to identify health outcomes that could be used in purchasing contracts for community and allied health services. The case study analysis uses a health services research approach that draws on multidisciplinary techniques including epidemiology, health services management and anthropology. The thesis describes the accountability interactions within the purchaser-provider model. Accountability is not a uniform construct. It consists of many domains, levels and interactions. In health service delivery, there are a number of different actors and a wide range of interactions for which they are accountable. Two important interactions are identified: professional accountability, which describes the accountability of the health service professional to their patient; and contractual accountability, which is the obligation of the health service provider (or providing organisation) to the purchaser through their contractual agreement. I conclude that health outcomes are not an appropriate domain of contractual accountability but they are an important component of professional accountability and I discuss the implications of these finding for theory and practice.