What is value in healthcare?

By Dr Sarah Jane Bailey

I want to tell you about my friend’s experience of healthcare. Let’s call him Dave. Dave is normally fit and well, he is in his thirties and he is self-employed. A few years ago he underwent a series of investigations and treatment at his local hospital and I accompanied him to his first outpatient appointment.

The clinic appeared to be running over an hour late but this wasn’t explained to us. We were commanded from one waiting room to another by computer screen announcements. We were worried we were sat in the wrong place and anxious we could be missing the long-awaited appointment. Occasionally a frazzled member of staff would pass by the seating area, head down avoiding eye contact. We managed to stop one nurse to ask if we’d been forgotten but they didn’t know; they were handling a different consultant’s list. Dave had planned a morning off work for the appointment but as the delay lengthened, his phone start ringing and emails began to ping. The waiting room wasn’t the appropriate place to conduct business but more importantly, Dave did not want to start a professional conversation he would have to curtail if the doctor suddenly called his name.

The appointment itself went well. The doctor was thorough and made a clear plan. Further investigations and surgery followed, however every result and every next step had to be chased. Phone calls went unanswered, periods of sitting on hold for 10 minutes or more, voicemails left for the consultant’s secretary forgotten. I’m sure this story sounds familiar.

Dave was an empowered patient and knew a lot about his condition but, nevertheless, he became downtrodden by the consistent setbacks and difficulties. He knew what the doctor had recommended all those months ago and he took the responsibility to ensure the plan was followed through and each result was received. However, not everyone is able to, willing to or aware they might need to take on this responsibility for their own patient journey. The curtain has not yet fallen on the end of an era of patriarchal medicine. It makes me wonder what happens to the person who gives up and leaves clinic without being seen? What about the person who assumes they don’t need surgery after all because they haven’t received a date?

Dave is back living his life without limitations now. Looking back, does he wonder if this process was a necessary inconvenience in order to be made well again? I’m sure he would agree that this was a small price to pay for good health. I wonder though, does it have to be so difficult and frustrating? Is it too much to ask for both a streamlined process and a good health outcome? Is a system where staff are so overworked that they cannot find time to apologise to a waiting room of anxious patients the best we can do? Is a doctor who is forever overbooked and running behind time truly productive? Do the hours lost from work (or other commitments) by the patient matter? And what about the extra appointments created for GPs, outpatients and A&E by people struggling to navigate the system, and those who have avoidable complications or complaints?

Until my year as a National Medical Director’s Clinical Fellow, I hadn’t really given much thought to the question: what is value in healthcare? As a hospital doctor, I went to work every day to do my best for my patients. Although I had recognised that sometimes I could offer a cure, more often than not my role was to help patients manage symptoms of chronic conditions and terminal illness. The most rewarding part of my job was not diagnosing and treating the diseases I had spent six years learning about in medical school. Instead it was meeting people, making a connection and using my knowledge and experience to explain, empower and alleviate anxiety. I believe I did this well for the patient while they were in front of me; however I confess feeling little sense of responsibility or ability to engage in the myriad of systems that made up the wider context of a patient’s healthcare journey.

As part of this year’s fellowship, I have learnt more about value in healthcare and the oft-cited definition[1]:

 

Quality (outcomes + patient experience of the intervention)

Value =        ___________________________________________________________________

Cost (direct + indirect costs of the intervention)

 

The literature explains that low value care occurs when an intervention is ineffective, inappropriate or poorly cost-effective. Delays, poor quality care, iatrogenic harm and complications all lead to poor value care. Importantly, the costs of an intervention logged in the Porter equation above aren’t as simple as the price of a medication, we need to consider the wider patient, provider, societal and environmental costs too. Equally quality is difficult to measure; patients and clinicians may have different views on what success looks like and there will undoubtedly be individual variation.

The OECD reported in 2017 that up to a fifth of health spending could be channelled to better use[2]. Given the efficiency savings asked of the NHS over recent years and the underfunding in this time of austerity, The King’s Fund called for action at all levels “to maximise the value of every pound spent on patient care”[3]. While staff costs, industry drug prices, technology and estates all contribute to the cost of the NHS, clinicians play a significant role as ‘cost-drivers’ as they guide the management plans of each individual patient. Yet the current centrally-driven payment models are not well understood by many staff on the front-line, making it difficult to motivate those who could save money across a population but are also responsible for maintaining clinical quality for each individual patient.

While I disagree that cost-saving should ever be the primary motivation for treatment decisions made by frontline healthcare staff, value should be. I was taught at medical school about the value of the doctor-patient relationship, the trust and the responsibility enshrined by the Hippocratic Oath. This was always in the context of doing right by the patients under my care. Less emphasis was placed on the wider patient population who might be competing for the same resources; be it funding, beds, or staff. This is a real conundrum for doctors working in a system of finite resources, time often being the resource most under strain. This concept of the conflicting role and responsibilities of a doctor to the patient in front of you versus the wider public is worth reflecting on as a profession. We have a responsibility to safeguard precious healthcare resources so that they are used to their maximum value while still delivering the best care we can to each individual.

In England, the initiatives RightCare[4], Choosing Wisely[5] and Getting It Right First Time[6] are beginning to address improving value and unwarranted variation in the NHS at a system level. But have they taken the public and the profession with them on their journey? NHS England has already come under fire from some patient groups for its consultation to reduce prescriptions of low value items[7].

So to conclude with my friend; Dave accepts the value of his treatment which resulted in his ability to return to normal life free from complications. However it is unclear where the 18 months of frustration, anxiety and stress along with hours of missed work fits into the traditional model of value, which is based on affordability and good health outcomes. Conversations about value in healthcare tend to focus on reducing costs, maximising efficiency and, more recently, minimising unwarranted variation. These are important challenges. But to really understand value, we also need to develop a deeper understanding of what patients (and clinicians) value most from their healthcare. The Royal College of Physicians, London defines value more broadly as the balance between:

  • population health and wellbeing outcomes
  • individual quality of care including patient experience
  • sustainability (financial, resource and environmental considerations).

The RCP definition uniquely combines a population, system and individual perspective. The best possible care should be safe, effective, person centred, timely, efficient and equitable[8]. Success requires a system-level approach with multiple partners and recognition of the need to improve the quality of care for patients today without compromising health and care provision in the future.

We will be exploring this important topic in more depth as part of the Royal College of Physician’s Our Future Health programme[9]. We want to identify the challenges and enablers to delivering value in healthcare within the NHS and what needs to change in order for us to improve. This is an area that has potential to greatly improve the way we structure resources and could transform the patient experience for the better. If you are interested in hearing more, join our journey:

  • follow our blog series on different aspect of value in healthcare
  • listen to our expert panel discussing what value means to patients and their clinicians
  • watch our video showcasing how sustainability fits into value in healthcare
  • look out for the animation we will produce from discussions at our July roundtable
  • join the debate #ourfuturehealth[10].

[1] Porter M. What is value in health care? N Engl J Med. 2010;363:2477-2481.

[2] OECD. Tackling wasteful spending on health. Paris: OECD; 2017.

[3] Alderwick H, Robertson R, Appleby J, Dunn P, Maguire D. Better value in the NHS. London: The King’s Fund; 2015.

[4] https//www.england.nhs.uk/rightcare/

[5] http://www.aomrc.org.uk/quality-policy-delivery/healthcare-policy/choosing-wisely/

[6] http://gettingitrightfirsttime.co.uk/what-we-do/

[7] https://www.england.nhs.uk/2017/11/prescription-curbs-to-free-up-hundreds-of-millions-of-pounds-for-frontline-care/

[8] Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press; 2001.

[9] https://ourfuturehealth.rcplondon.ac.uk/

[10] https://twitter.com/RCPFuture

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