Value and population health: an NHS Provider perspective
By Chris Packham
Providing good-value healthcare
For 65 of its first 70 years the NHS operated as a system designed to try and provide equitable, good-value healthcare for as many citizens as possible to a uniform standard. We succeeded: most world assessments of healthcare systems placed the UK near the top of league tables in balancing resources and achieving outcomes. Part of that success included the underpinning of ‘population health’ techniques. For most of those 65 years a public health driven, utilitarian approach was a core element of UK healthcare planning, and in many ways was also core to individual medics’ understanding of how the system is supposed to work.
What of the last 5 years? Changes in society and services have begun to manifest as a flattening or even a rise in mortality in some areas – we may well be looking at the next generation experiencing a life expectancy fall.
Closer to home for me, sadly, are the reforms of 2012 that removed public health specialists from the NHS (except screening and specialised commissioning) and made what advice they may have been able to offer the NHS ‘arms-length’. Despite the logic and success of the newly-created Public Health England, their advice was just that – advisory. Does it matter that the majority of such advice was removed from the front line of the NHS?
Yes, it matters tremendously.
Losing its way – value undermined
The NHS has visibly swung away from some of what underpinned its success: prevention, an understanding of local population needs, systematic clinical needs assessments and pathway development. Instead, we now have often poorly-evidenced or prioritised local commissioning and front line providers who are understandably focused on more immediate Trust matters, such as dealing with acute demand.
Commissioning GPs have a good knowledge of their own patients but there are challenges to a population health overview that require the expertise of other specialists.
Asking the right questions
I recently sat in a clinical cabinet where a senior physician was unhappy with a tendering decision made by local commissioners to change rehabilitation services because, they argued, it put the excellent in-hospital mortality statistics of their stroke service at risk. However the more pressing problem, in my opinion, was the community mortality statistics for stroke in the local area, which were in the bottom 10% for stroke mortality nationally – but this was not considered in the discussion. Sir Muir Gray suggested asking this question to test if population approaches are being used or discussed:
“If I am a respiratory physician serving a local area, am I seeing the 300 new patients each year that need my attention the most from that area?”
What of ‘value’?
The RCP have particularly stressed the importance of patient experience and opinion as part of judging value. This echoes the triple value of Rightcare: patient experience, allocative efficiency and technical efficiency. Not all physicians may be familiar with the latter two concepts but they will be only too aware of directorate budgets being cut or logical interventions not being adopted.
In a provider Trust, we must not forget that value expressed in this way must be underpinned by the clinicians who work there. Clinicians should understand the rationale for resource decisions and the system should ensure their expertise is used and valued when Trusts make those decisions. Staff well-being (including that of senior doctors) has been shown to dramatically improve patient experience and outcomes.
Reinventing population health
If we keep population health in mind as well as ensuring that our own part of the broader system functions efficiently, the real expertise of physicians will be better harnessed for the population as well as current patient caseload benefit. In 2004 Derek Wanless (a Merchant Banker) was asked by the Department of Health to come up with a set of options to address affordability of future healthcare. He came to one conclusion. Maximise prevention quickly – but this wasn’t adequately addressed. A decade later, Simon Stevens published the Five Year Forward View that reiterated the same advice. Instead, NHS funded prevention budgets were handed to Local Authorities in 2012, and in almost all cases have been severely cut across England. Smoking cessation, alcohol treatment and sexual health services in some areas have shrunk and in no way meet need.
We know from Michael Marmot’s work that addressing the wider determinants of health (upstream) makes the biggest difference, but NHS action can make a real and marginally very important difference to health – both by promoting (secondary) prevention and by promoting balanced, cost-effective healthcare pathways (triple value).
Taking a population health approach within a provider organisation can make a huge difference to the health experiences of many particularly disadvantaged groups. Patients with severe mental illness, for instance, have mortality rates from CVD some 400% higher and for GI disease (including alcohol-related disease) some 550% above population average, both contributing to a 15 year shorter life expectancy. The role of the NHS here and now adds real value to healthcare for such patients, many of whom do not engage with usual primary care.
So we have faced the last five years with cuts to prevention budgets, and often breakdowns in rational planning and commissioning of services based on value.
The NHS needs to act. Let’s reinvent our concept and execution of population health strategies and rejoice that health Provider Trusts can not only contribute, but take on lead roles.
The expertise of Trust clinicians considering the whole system, with modest but dedicated specialist support, and alongside GP commissioning colleagues, could make a systematic public health utilitarian approach real again. Then we can really see how physicians can support and lead value-based healthcare.
Dr Chris Packham is the associate medical director of Nottinghamshire NHS Foundation Trust and leads on the trust’s public health strategy.