IDEA LAB

Value: the next revolution in healthcare policy thinking?

Anant Jani is Executive Director of Better Value Healthcare and is a researcher in the University of Oxford Value-based healthcare programme. Over the past two years he has been a steering group member for an AbbVie UK-sponsored ‘Decisions with Value’ project, creating practical guides for the NHS on how to put value at the heart of commissioning. He talks to us about the potential this concept has to improve outcomes.

IDEA LAB

Value: the next revolution in healthcare policy thinking?

Anant Jani is Executive Director of Better Value Healthcare and is a researcher in the University of Oxford Value-based healthcare programme. Over the past two years he has been a steering group member for an AbbVie UK-sponsored ‘Decisions with Value’ project, creating practical guides for the NHS on how to put value at the heart of commissioning. He talks to us about the potential this concept has to improve outcomes.

How do we distinguish between cost and value in healthcare?

Anant Jani: Value encompasses cost, through optimising resource utilisation, and also addresses outcome improvement.

 

Outcomes come in various forms. Process and clinical patient outcomes are what health services are typically good at measuring (for example, are our operating theatres meeting safety specifications?). But subjective patient outcomes/needs (whether someone can play with their grandchildren after knee surgery, for example) matter too. We are doing a very poor job at giving these needs due weight.

 

Finally, as well as looking at the patients who are making it to the services; we need to identify who we are missing – the unmet need. This represents population level outcomes.

 

Balancing individual and population need is difficult.  Value-based decision making is about realising we are not going to be able to fully satisfy every individual need within the overall available budget. England’s £120bn has to be allocated for maximal impact across the whole population.

How does that balance get best struck?

AJ: All healthcare systems are facing increasing demand due to growing and aging populations and decreasing resources. In Decisions with Value we aimed to collect tools and case studies on best practice to address these problems because if we do not address this through a value lens, we face the prospect of widespread preventable suffering of individuals and populations.

 

Balancing patient and population needs can only be done by an open and fair discussion. Do we currently have a good model? I don’t think we do. But this is something we need to work on and develop innovative approaches for. Through NICE, England does a good job at making some decisions transparent, which is something many systems can learn from – but that is a step short of open dialogue.

 

One great example is Northumbria, where they had 80 public consultations over an 8 month period to communicate more directly about how priorities were being formed and how decisions were being made on redesign of services.  That is the kind of open dialogue that is necessary.

 

There are pockets of great practice across Europe. The Dutch have done a good job on dialogue on what the public do and don’t want. One example would be screening for Familial Hypercholesterolemia which people felt was quite intrusive in that screeners were going into households and screening for FH. There was dialogue about that and although there was population benefit to screening in this way and early intervention for at-risk screened individuals, it was seen as an invasion of privacy and so they stopped.

 

There is no magic formula that gets the right answer, only dialogue will allow a population to decide what is a priority. People in Italy are going to have different priorities to those in the Netherlands, or Germany.

Anant Jani

Balancing patient and population needs can only be done by an open and fair discussion. Do we currently have a good model? I don’t think we do. But this is something we need to work on and develop innovative approaches for.

What is the role of prevention in value-based care? Is it playing enough of a role?

AJ: Preventative care can help to reduce demand – but prevention is not free and does require investment. Given the incentive structure of many health systems built around fee for service models, there isn’t enough incentive to invest in preventative healthcare.

 

Insurance-based systems like Germany or the Netherlands are better incentivised to invest in preventing ill-health and keeping people healthy to reduce costs of care.

 

Taking a longer term view on what a provider is paid to deliver can help. Preventative healthcare measures may only start demonstrating their value over 5-10 years. Commissioning cycles need to reflect this – single year cycles just aren’t equipped to deliver these kind of preventative population level results.

 

What advice do you have for stakeholders in other countries aiming to adopt this approach?

AJ: Start with a clear understanding of what the system is trying to achieve and to whom you are ultimately accountable and what are you holding yourself accountable for. Accountability is where outcomes come into play – are they process outcomes, population outcomes, patient outcomes? Then layered across all of that is good resource (finance, time, space) stewardship. In Decisions with Value we are putting together a conceptual framework that cuts across whatever systems and processes are currently in vogue to focus on what is eternal in healthcare – patients and their clinical conditions/needs.

 

What learnings did you draw from participating in Decisions with Value?

AJ: A sense of hope, as there are so many fantastic people.  Talking with the fellow steering group members working on projects as diverse as COPD services and eating disorder interventions it is consistent that it can take 2-3 years to get a good initiative off the ground.

 

These are the heroes of the healthcare system who are going above and beyond to get these things done. It really needs a proactive nature and the sense of responsibility to put patients at the heart to make these value-based approaches happen. These people aren’t waiting for opportunities to arrive – they are going out and creating their own opportunities because they are holding themselves accountable to the patients and populations they serve.

 

There are people like this across Europe. We did a value based healthcare congress in Germany in 2016 and we are working with the HPI Potsdam to help design thinking around healthcare innovation. In Italy we are working with the National Institutes of Health there on value-based healthcare. In Netherlands and Madrid we are working with universities on value-based approaches to clinical genetics.  Decisions with Value will find an eager audience across the continent – the appetite for this thinking and approach is already there.

 

Quality and evidence-based medicine took a long time to get off the ground but is now everyday practice. The more we do, the quicker we will deliver value-based healthcare so I am hopeful that the momentum is building.

 

Ultimately, value-based healthcare is common sense – why wouldn’t we want to improve outcomes and optimise resource use?

Download the eu whitepaper