Outcomes, Value & Stewardship Resources
Select a section to explore the glossary, acronyms or determinants of health.
Acronyms and Terms
This directory lists acronyms and terms used in the Outcomes, Value and Stewardship glossary, with brief explanations.
- AOMRC – The Academy of Medical Royal Colleges.
- Fingertips – A large public health data collection online platform that provides easy access to in-depth analysis of a wide range of health and health-related data at national, regional and local level. It brings together data from multiple publicly available sources in one place, allows benchmarking, data export, and helps identify behavioural priorities.
- GHG – Greenhouse gases.
- GIRFT – Getting It Right First Time: a national NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking and a data-driven evidence base to support change. Incorporates RightCare.
- HES – Hospital Episode Statistics – collects data on all NHS-funded secondary care activity in hospitals in England, including admissions, outpatient appointments and A&E attendances, used for healthcare analysis and commissioning.
- MHRA – Medicines and Healthcare products Regulatory Agency, the UK regulator for medicines, medical devices and blood components for transfusion, an executive agency of DHSC.
- MHS – Model Health System (previously Model Hospital). A data-driven improvement tool that supports health systems and trusts to improve patient outcomes and efficiency by benchmarking services and costs.
- NHSBSA – NHS Business Services Authority – an Arm’s Length Body of the Department of Health and Social Care.
- NICE – National Institute for Health and Care Excellence, providing national guidance and advice to improve health and social care.
- NIHR – National Institute for Health & Care Research, which funds and supports health and social care research to improve health and wellbeing and promote economic growth.
- OHID – Office for Health Improvement and Disparities, a DHSC unit responsible for public health policy and initiatives in England, focusing on improving population health and reducing inequalities (replacing Public Health England).
- PALS – Patient Advice and Liaison Service – an NHS service providing confidential advice and support to patients, families and carers.
- PaPi – Population and Person Insight, an NHS England initiative for population health management.
- PHOF – Public Health Outcomes Framework, setting a vision for public health, desired outcomes and indicators, and the associated Fingertips tool to view and interact with the data.
- PLICS – Patient Level Information and Costing System, which records costs at individual patient level across providers; supported by NHS England’s Costing Transformation Programme.
- PROMS/PREMS – Patient Reported Outcome Measures / Patient Reported Experience Measures.
- QALYs – Quality-Adjusted Life Years, combining quantity and quality of life to assess the value of interventions.
- RightCare – An NHS England programme focused on population health and optimal value, whose tools and products are now incorporated in GIRFT.
- RTT – Referral to Treatment waiting time statistics in the NHS.
- SUS – Secondary Uses Service, which collects monthly commissioning data sets (CDS) from provider organisations, used for commissioning and analysis.
- UKHAS / UKHSA – UK Health Security Agency, which prevents, prepares for and responds to infectious diseases and environmental hazards.
Determinants of Health
Summary of the causal determinants of health described by Anant Jani, organised into social, environmental, digital, commercial and political determinants.
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Social determinants of health (S-DoH)
Conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping daily life (WHO 2024).
Examples:
– Responsible for a large proportion of health inequalities within and between countries.
– Include income, employment, housing, access to safe drinking water and nutritious food.
– Education shows a dose–response relationship with all-cause mortality; every additional year of education is associated with a 1.3–2.9% reduction in risk of all-cause mortality (IHME–CHAIN 2024).
– Unemployment and job insecurity are linked with increased risk of death, physical ill health, poor mental health, depression and anxiety (Bambra 2020; Hensher 2020; World Bank 2020). -
Environmental determinants of health (E-DoH)
Global, regional, national and local environmental factors that influence health, including climate, air, water, soil, ecosystems and biodiversity, as well as man-made environmental hazards (Gibson 2017; PAHO 2024; Romanello et al 2023).
Examples:
– Climate change-linked extreme weather events like heat, flooding and storms are increasing in frequency and intensity. Between 2000–2004 and 2017–2021, there was an increase in the global average of 86 days of health-threatening high temperatures annually.
– Increased heatwave days and drought in 2021, compared to the 1981–2010 baseline, resulted in an additional 98 million people experiencing moderate–severe food insecurity.
– Environmental hazards such as electronic waste, nanoparticles, plastic pollution (micro- and nanoplastics), and hazardous chemicals (e.g. lead, toxic pesticides) have major health impacts. -
Digital determinants of health (D-DoH)
Conditions related to the availability, accessibility, affordability, acceptability and quality of digital technologies and data (mobile devices, internet, apps, telehealth, AI, etc.) that influence health and access to services (Chidambaram et al 2024).
Examples:
– As of 2021, there were over 3 million applications on Google Play and Apple App Store combined, a large proportion of which were health and fitness apps.
– Digital exclusion (lack of access or skills) can widen health inequalities if services move online without support. -
Commercial determinants of health (C-DoH)
Systems, practices and pathways through which commercial actors drive health and equity, including strategies used by corporations to protect and grow market share.
Examples:
– Four industries (tobacco, unhealthy food, fossil fuels and alcohol) are linked to at least a third of global deaths every year (Rollin et al 2023; WHO 2024).
– Marketing, pricing, product placement and lobbying can all influence patterns of disease and risk behaviours. -
Political determinants of health (P-DoH)
The role of government, governance structures, party politics, ideologies and policies at local, national and global levels in shaping health and health equity.
Examples:
– Policies that ban smoking lead to improved health outcomes (Frazer et al 2016).
– In the UK, the sugar sweetened beverage tax is estimated to have prevented or postponed at least 17,000 cases of obesity in girls and 5,000 in boys between 2014–2020 (Andreyeva et al 2022; Rogers et al 2023).
– Decisions on welfare, taxation, housing, transport, planning and trade all have health implications.
Commissioning is the continual process of planning, agreeing and monitoring services. Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment.
NHS website www.england.nhs.uk 14/4/25
In order to monitor the efficacy of the commissioning function, metrics need to cover outcomes, quality, efficiency, and patient experience, and should draw on multiple complementary data sources.
Outcomes
- Mortality rates from ONS/SHMI
- Disease incidence & prevalence (e.g. diabetes, COPD, CVD) from OHID/PaPi
- Health inequality gaps – life expectancy, deprivation related from Fingertips/JSNAs
- Service uptake by demographic group (ethnicity, socioeconomic status, geography)
- Equity audits (e.g. immunisation, screening uptake)
Quality & Patient Safety
- Readmission rates
- Never events and serious incidents (StEIs/LFPSE)
- CQC reports
- Compliance with NICE standards through audit (e.g. stroke, cardiac, cancer)
Efficiency / Value / Service Access
- Cost per patient or per outcome from Model Health System, NHS Benchmarking Network, PLICS
- Greenhouse gas (GHG) emissions per patient or per outcome
- Variation in service utilisation and outcomes from health expenditure benchmarking and programme budgeting data where available
- Prescribing efficiency from MHRA and NHSBSA data
- RTT waiting times, A&E waiting times, cancer 62-day target
- GP appointment availability and access
- Rates of hospital admissions for ambulatory care sensitive conditions (proxy for effective primary/community care)
Patient Experience
- Friends & Family Test and GP Patient Survey
- PROMS/PREMS
- NIHR feedback studies
- Complaints and compliments – PALS, Healthwatch
- Staff reported experience – quality of support
Equity and Reducing Health Inequalities
- Service uptake by demographic group (ethnicity, socioeconomic status, geography) – NHSE EDS
- Equity audits and reports (e.g. immunisation, screening uptake) – UKHSA, PHOF
“Culture is the shared tacit assumptions of a group that it has learned in coping with external tasks and dealing with internal relationships.”
Schein EH (1999) The Corporate Culture Survival Guide. John Wiley & Sons. p.186.
Although culture is intangible, it can be monitored and evaluated through stakeholder relationships by using a combination of qualitative and quantitative measures. Value-based healthcare depends on collaboration so indicators need to capture shared assumptions.
First identify cultural attributes (e.g. openness & transparency, co-creation, patient centred, continuous improvement) and link these to value-based goals such as better outcomes, equity and cost-effectiveness.
Outcomes linked to culture
- Reduction in unwarranted variation and operational metrics (e.g. Atlases, RightCare, PROMs)
- Workforce – retention, sickness absence, whistleblowing rates
- Partnership – jointly delivered pathways, speed of cross-system decisions
Governance & accountability
- Board assurance frameworks
- Integrated performance reports
- Progress against the quadruple aim (treating culture as strategic)
A network is a set of organisations and individuals that deliver the system’s objectives.
A system is a set of activities with a common aim, a common set of objectives, and a set of criteria against which progress towards the outcomes that matter can be measured. An approach to delivering a population-based system could be via an Accountable Care Organisation (ACO).
A pathway is the course an individual follows as they go through the system.
Network outcomes (collaboration & shared improvement)
Examples: cancer alliances, stroke networks, maternity networks.
- % of member organisations regularly attending and contributing to network meetings
- Number of joint initiatives launched
- Reduction in unwarranted variation in care between providers
- Shared definitions and clinical guidelines in use
- Variation in outcomes by geography or deprivation (e.g. cancer survival rates)
System outcomes (population health & value)
- Population health outcomes – life expectancy, preventable admissions, smoking prevalence, obesity rates
- Performance – emergency readmissions, hospital-acquired infections, A&E 4-hour standard
- Efficiency – bed occupancy, delayed discharges, waiting times, cost per capita
- Experience & equity – Friends & Family, staff survey, reduction in health inequalities
Pathway outcomes (patient journey, e.g. cancer or stroke)
- Clinical effectiveness – mortality, readmission rates, recurrence
- Patient experience & quality of life – PROMs, PREMs, Friends & Family
- Timeliness – e.g. % diagnosed within 28 days of cancer referral, door-to-needle times in stroke
Leadership sets direction and shapes culture. Management organises people and resources to deliver agreed objectives. Accountability demonstrates that public money and shared resources are being used wisely and transparently.
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Possible measures include:
- Clarity of outcomes and objectives in strategic plans
- Board and committee structures aligned to population health and value
- Evidence of transparent reporting (e.g. public board papers, quality accounts)
- Staff survey responses on confidence in leadership and management
- Follow-through on audit, CQC and improvement recommendations
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Population health is the health outcomes of a group of individuals, including the distribution of those outcomes within the group.
Population healthcare/medicine focuses on planning and delivering services for defined populations with a shared health need.
Population health management uses linked data and segmentation to target interventions for defined population groups.
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Measures typically include:
- Life expectancy and healthy life expectancy
- Disease incidence and prevalence by population group
- Inequality gaps (e.g. by deprivation, ethnicity, geography)
- Preventable mortality and amenable mortality
- Service utilisation and access by segment
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Precision medicine, stratified medicine and personalised medicine/healthcare all refer to approaches that tailor interventions to specific sub-populations or individuals, based on characteristics such as genetics, biomarkers, clinical profile, risk or preferences.
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Measures might include:
- Outcomes (e.g. response rates, survival, complications) in specific sub-groups
- Reduction in adverse events through targeted treatment
- Cost-effectiveness of targeted vs routine approaches
- Equity of access to personalised approaches
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Programme budgeting describes how resources are allocated across programmes of care (e.g. respiratory, cardiovascular, mental health). Marginal analysis compares the marginal costs and benefits of shifting resources between programmes to improve value.
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Measures typically involve:
- Spend per head by programme or condition
- Outcomes and activity by programme
- Comparisons to benchmarks or other systems
- Modelling of the impact of shifting marginal resources
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Resilience is the ability of a health service to cope with challenges, first described by WHO following analysis of how well health services coped with the Covid pandemic, but relating to all major challenges such as population ageing and growing demand when resources are finite.
WHO describes resilience in three phases:
- Absorptive capacity – coping during shocks (e.g. pandemic, surges, extreme weather, supply disruption)
- Adaptive capacity – adjusting to ongoing stresses (e.g. staff shortages, ageing population, climate change)
- Transformative capacity – long-term system change (e.g. digital, integrated care, low-carbon models, circular economy)
WHO also identifies six building blocks:
- Service delivery
- Health workforce
- Information systems
- Access to medicines & supplies
- Financing
- Leadership & governance
These can be assessed using data from SitReps, Model Health System and performance dashboards, for example:
- Staff – workforce capacity, sickness, vacancy, retention, wellbeing
- Stuff – availability of PPE, oxygen, critical equipment
- Space – bed occupancy, surge and ICU capacity
- Systems – coordination, communication, digital resilience
Stewardship is a culture in which people who do not own something are committed to ensuring its survival for future generations.
“Stewardship is to hold something in trust for another.”
Block P (1996) Stewardship: Choosing service over self-interest, Berrett-Koehler.
Evaluation of stewardship focuses on culture and behaviour around resource use:
- Staff surveys on integrity, fairness, attitudes to improvement and resource use (including environmental)
- Clinical outcomes and improved patient outcomes
- Audit and feedback on resource use and waste reduction
- Governance indicators – integration of stewardship principles in decision-making
- Transparency and accountability mechanisms
- Patient and public involvement in decisions about resource use
A strategy is a coherent collection of actions that has a reasoned chance of improving results.
Friedman M (2005) Trying Hard is Not Enough: How to produce measurable improvements for customers and communities. Trafford Publishing, p.20.
The military distinguish clearly between strategic, operational and tactical decision-making.
Each strategy (national, regional, organisational) should have a clear theory of change: what problem it is trying to solve, what outcomes are expected, and over what time period.
Measuring the success of a strategy requires a balance of qualitative & quantitative outcomes covering patient experience, staff experience, financial sustainability and system-wide impact.
Health outcomes
Clinical effectiveness: mortality, readmissions, complications, QALYs, disease prevalence, preventable admissions, health inequalities, service uptake (HES, QoF, ONS, performance dashboards).
Patient experience
Improved waits (A&E, RTT, cancer), GP access, MH referrals, PROMs, PREMs, Friends & Family, national patient surveys.
Workforce
Staff engagement, turnover, recruitment and retention, training uptake (Model Health System, staff surveys).
Operational & financial sustainability
Cost per episode, bed occupancy, agency spend, achievement of control totals, reduction in deficits, implementation of new technologies.
Environmental sustainability
Progressive reduction in direct and indirect GHG emissions (buildings, transport, medicines, supply chain); metrics such as GHG per bed day, per patient episode or per m²; biodiversity; mitigations for eco-toxicity.
System-level integration & collaboration
Cross-organisational data sharing, reduction in duplication, discharge coordination, community follow-up rates, evidence of “left shift” to community care.
The structure is the organisation or set-up, which may be a bureaucracy, a market or a network.
The process is the set of activities (e.g. number of operations done).
The outcome is the result of the process.
Outcomes that matter to health and social care are the results of interventions that indicate that high value is being realised for individuals and populations.
Outcomes that matter to individuals are the results people care about most and they often differ from outcomes regarded as important by clinicians or managers. ICHOM has produced good standard sets of outcomes (see ICHOM website).
For measurement for improvement, each term needs clear measures:
Structural measures
- Staffing levels – numbers, grades, skill mix
- Availability of equipment, theatre and clinic capacity
- Bed capacity
- Funding allocations and financial flows
- Service directories and network maps
Process measures
- Number of appointments, procedures, visits (HES, SUS)
- Waiting times (NHS waiting lists data, performance dashboards)
- Compliance with guidelines (clinical audit)
- Readmission rates
- Operational performance metrics
Outcome measures (system)
- Mortality (e.g. 30-day post-surgery) – ONS, HES
- Disease prevalence & incidence – ONS, OHID
- Life expectancy – ONS
- Length of stay – HES
- Avoidable admissions and readmissions – HES
- Cost-effectiveness – finance and performance data, Model Health System
Outcome measures (individual)
- Quality of life
- Ability to live independently
- Pain management
- Emotional wellbeing and mental health
- Satisfaction with care and support
- Achievement of patient-defined outcomes
Sustainability in Quality Improvement (SusQI) is a framework of four stages for embedding sustainability in improvement projects, to ensure high-quality, low-carbon care and maximise sustainable value.
- Setting goals: Including sustainable goals – maximise health outcomes with minimum financial and environmental impact, adding social value where possible.
- Studying the system: Recognise environmental and social resource use in the current system and identify opportunities to improve.
- Designing the improvement: Use principles of sustainable healthcare (prevention, patient empowerment, lean pathways, low-carbon alternatives).
- Measuring the impact: Measure the impact of the project on sustainable value, including social and environmental impacts.
Sustainable value measures as outlined under Sustainable Healthcare in the Outcomes section (health outcomes, environmental impacts, social impacts, financial impacts).
Productivity relates the outputs of a service to the inputs.
Efficiency relates the outcomes of care to the inputs, namely the resources used for that group of patients; this is the meaning of value as used in some systems but, here, technical value is part of a broader concept of value.
Cost-effectiveness relates the outcomes of a technology or intervention to the costs, often expressed as cost per QALY or cost per unit of health gain.
Technical value (sustainable value) = patient & population outcomes / (environmental + social + financial resources).
Productivity
- Outputs (activity) – admissions, outpatient attendances, GP consultations, A&E attendances, diagnostics
- Inputs – workforce FTEs, total expenditure, bed days, capital assets, environmental resources (e.g. GHG emissions, water use)
- ONS healthcare productivity index
Efficiency
- Outcomes – mortality, readmissions, PROMs, complications
- Inputs – costs, workforce, bed days, GHG emissions
- Efficiency ratios – cost/GHG per QALY; £ per reduction in readmission; £ per PROM improvement
Cost–effectiveness
- Economic evaluation – Incremental Cost-Effectiveness Ratio (ICER) = (Cost_new – Cost_current) ÷ (QALYs_new – QALYs_current)
- Direct costs – staff, drugs, equipment; indirect costs – follow-ups, complications
- Effectiveness – QALYs, disease-specific measures (e.g. HbA1c)
Efficacy is the magnitude of benefit demonstrated in research settings (e.g. RCTs).
Effectiveness is the degree to which an intervention with proven efficacy delivers benefit in routine service settings.
Efficacy can be measured using trial data (NIHR, MHRA etc.), typically against outcomes such as mortality, symptom scores, risk reduction.
Effectiveness can be measured using NHS data to assess performance in practice:
- Admissions avoided, survival rates, QALYs gained
- Pre–post comparisons
- Routine audit
- Prescribing patterns
- PROMs
Empathy is the ability of clinicians and staff to understand and respond to what matters to individuals, seeing situations from their perspective.
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Potential measures include:
- Patient experience survey items relating to feeling listened to and understood
- Qualitative feedback and stories
- Complaints and compliments relating to communication and respect
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Inequalities are differences in health outcomes or access between groups. Inequities are those differences that are avoidable, unfair and systematically linked to social disadvantage.
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Measures typically involve:
- Outcome differences between groups (by deprivation, ethnicity, geography, disability, etc.)
- Access and utilisation differences (e.g. screening uptake, waiting times)
- Monitoring of “core20PLUS5” or similar frameworks
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Terms used by clinicians to describe the value of interventions:
- Necessary – essential to prevent death or serious harm.
- Appropriate – justified given the evidence, context and patient preferences.
- Inappropriate – unlikely to benefit, or where risks outweigh benefits.
- Futile – no expected benefit for the individual.
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Possible measures:
- Clinical audit of procedures against evidence-based indications
- Use of peer review or MDT review to classify interventions
- “Choosing Wisely” or similar campaigns tracking reduced low-value care
Overuse is the provision of healthcare services where the likelihood of harm exceeds the likelihood of benefit, or where the benefit is trivial relative to cost and risk.
Measures of overuse might include:
- High procedure rates compared to benchmarks without corresponding outcome benefit
- Rates of investigations outside guideline recommendations
- Polypharmacy indicators (e.g. % of older people on ≥10 drugs)
Quality is often described as care that is safe, effective, person-centred, timely, efficient, equitable and, increasingly, environmentally sustainable.
(You can align this with your preferred framework.)
Measures will typically cover:
- Safety – incidents, harms, never events
- Effectiveness – outcomes, compliance with guidelines
- Experience – PROMs, PREMs, Friends & Family
- Timeliness – waits, delays
- Efficiency – resource use per outcome
- Equity – differences between groups
- Sustainability – environmental impacts
Shared decision-making means clinicians and individuals working together to choose between reasonable options, including the option to do nothing, based on evidence and what matters to the person.
Possible measures:
- % of eligible patients recorded as having received decision support
- Use of decision aids in key pathways
- Survey items on involvement in decisions
- Rates of preference-sensitive procedures
Sustainable healthcare means meeting healthcare needs now, for everyone, without compromising the ability of future generations to do the same.
It uses principles such as: reducing healthcare need through prevention; empowering patients; designing lean pathways; prioritising low-carbon alternatives; and efficient operational resource use.
The broader view of value, “to maximise health gain with minimum financial cost and environmental harm, whilst adding social value at every opportunity”, is sometimes referred to as sustainable value (Mortimer et al 2018).
Sustainable value measures include consideration of:
Health outcomes for patients
- Morbidity and mortality
- Compliance with standards of care
- Avoidable admissions or reduced bed days
- Number of encounters (e.g. “one-stop” models)
- PROMs
Wider population outcomes
- Public health benefits or risks
- Improved access for others through avoided admissions or more efficient models
Environmental impacts
- Reduction in travel, water, energy or resource use
- Change in carbon footprint of a process or pathway
- Reduced pollution, improved biodiversity
- Climate resilience and adaptation measures
Social impacts
- Changes in patient and family experience
- Changes in staff satisfaction (e.g. saved time, better processes)
Financial impacts
- Cost versus savings over time
Value is assessed by weighing up the benefits received by an individual, a group with a common need, or a population, against the resources used. It is essential to measure outcomes and to use the population as the denominator as well as the number of patients treated.
There are four perspectives on value: personal, technical, allocative and social.
Personal value
- % of people receiving elective surgery who had formal decision support
Technical value
- Measures of efficiency and equity of care for defined populations
Allocative value
- Spend on different segments of the population (e.g. people with respiratory disease), taking multimorbidity into account
Social value
- Understanding and influencing social determinants of health, not just individual behaviours
Warranted variation is variation in spend or provision of services that can be explained by differences in population need (e.g. haemoglobinopathy services in London vs Cornwall).
Unwarranted variation is “variation in the utilisation of health care services that cannot be explained by variation in patient illness or patient preferences” (Wennberg JE, 2010).
Publishing unwarranted variation (e.g. Dartmouth Atlas, NHS Atlases) prompts questions: if we are at the upper end of the range, is it overuse? If at the lower end, is it underuse and inequity?
Nationally, population-based rates of:
- Imaging
- Prescribing (e.g. antidepressants)
- Polypharmacy in older people
- Laboratory testing
- Elective surgery
- Admissions in last year of life
- Programme budgeting / expenditure benchmarking
At ICB level:
- Number of enquiries about possible overuse (if in top decile)
- Number of enquiries about possible underuse and inequity (if in bottom decile)
Maps of population-based variation are a key tool.
Waste is use of resources that would produce more value if used for another purpose or another subgroup of the population.
Types of waste include:
- Waste left after a job has been done
- Waste due to inefficiency
- Waste when resources do not achieve outcomes that matter
- Waste due to opportunity cost – when resources could produce greater value elsewhere
The concept of waste is often illustrated by Avedis Donabedian’s value–waste curve.
Practical measures include:
- Low-value procedures or tests with little outcome gain
- Duplication of tests or assessments
- Over-provision where outcomes are not improved
There is no single definition of health beyond the WHO’s statement that it is more than the absence of disease. The term wellbeing is increasingly used to describe how people feel about their lives and how satisfied they are.
Layard and de Neve describe wellbeing as a person’s inner subjective state – how happy they are and whether life feels worthwhile – not just external circumstances.
Evaluative measures (life satisfaction)
- ONS life satisfaction questions (0–10 scale)
- Workforce wellbeing scores from staff surveys
- Public Health Outcomes Framework indicators
Hedonic measures (affect)
- Measures of positive and negative affect in surveys
- GP patient surveys
- NHS Staff Survey
- Health Survey for England
Eudaimonic measures (meaning & purpose)
- ONS question “to what extent do you feel the things you do in your life are worthwhile?”
- Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS)