Traditionally providers of care focused on quality improvement, an assumption that better quality care would get better outcomes, and better outcomes at the lowest possible cost was the objective of healthcare. This is in fact called value in the United States, but in a country in which the whole population has been covered by a finite budget this is in fact efficiency. Providers need to ask questions such as:
Are there people in our population, (note the words ‘our population’ who have not been referred but would benefit more from our skills and resources than some of the people being treated)
Are there some people that we are treating who are not getting great benefit and if looked at in the cold light of day can be classified as examples of overuse, even though the treatment we gave them had evidence of effectiveness, in the scientific literature, and was delivered at high quality? and,
Have we got the bigger picture right? Is the balance between our various sub-specialties simply the outcome of decades of a service in which the most powerful clinician increased their service whether or not that was the greatest need for the population?
Obviously, commissioners have a very important part to play in optimising value, using the triple value definition of Rightcare:
- Personalised value, determined by how well the outcome in terms of alleviating the problem that was bothering them most relates to the values of each individual
- Allocative value, determined by how well the assets are distributed to different sub groups in the population
- Between programmes
- Between systems within each programme
- Within system
- Technical or utilisation value determined by how well resources are used for outcomes for all the people in need in the population not only optimising quality but also
- Are the right people being seen?
- Is high value innovation implemented?
- Is the balance right form prevention to long term care?
However it is clear that clinicians and providers also have to be involved in the value game.
I had the privilege of speaking at the NHS Providers conference and shared these ideas with a big and mixed audience and, although I am obviously biased, I can say I think they were well received. I also had the chance to share them with some young clinicians, the leaders of 2027-2037 in Salford and they too accepted that this would be part of their job in the years to come.
So, we can say that value is everybody’s business. There is a famous line produced by the Department of Health about thirty years ago which said that “the prevention of health is everybody’s business” “which means it is no one’s business.” We now need to build value based decision making into the minds of those who provide services.
Sir Muir Gray
Better Value Healthcare Ltd