Muir Gray

Optimising the value of interventions for populations

All clinician groups should estimate which interventions are most beneficial.

Value based healthcare.

Reducing unwarranted variation to maximise the value of healthcare for populations

Population healthcare: the third dimension

When clinicians think about healthcare, they usually think about primary, secondary and tertiary levels of care or generalist, specialist and super-specialist, to use another taxonomy. The latter taxonomy is perhaps more accurate because many people use more specialist services as their first point of care. These are well-established levels, but what is often overlooked, however, are the two other levels of care: self-care and informal care. Self-care is the most important type of care. Indeed, some people are now calling healthcare what people do for themselves with the professionals providing health services to support healthcare. Increasingly, it is recognised that even when people are receiving excellent technical care from a generalist, specialist or super-specialist, much depends on what they will do for themselves. The second neglected level of care is informal care that is provided by family, friends, neighbours and voluntary services. In spite of the complaints about an uncaring society, informal care remains of vital importance, and many informal carers are themselves people with long-term health problems. If people in their 70s, 80s and 90s gave up caring, then the NHS would collapse tomorrow. Thus, it is helpful to think about five levels of care: self-care, informal care, generalist care, specialist care and super-specialist care.

Optimising allocative value for populations

This article is primarily about optimising allocative value and the clinicians’s role in this task The aim is to achieve maximum allocative value, namely, the allocation at which it is not possible to achieve greater benefit for the population as a whole by shifting one pound from one budget to any other budget. There is no record of this having been advised anywhere. Although we sometimes talk about ‘the National Health Service in Italy’ or the ‘NHS in England’, namely, talk about a national bureaucracy, in most countries with a tax-based health service significant bureaucratic authority is delegated to a smaller population size. In England, the bodywith delegated authority is the Clinical commissioning groups; in the other UK countries, it is the Health Board. In countries where insurance plays a bigger part than taxation there are also bureaucratically defined populations, people registered with one insurance company for example, and new names evolve to express this type of institution, for example, the Accountable Care Organisation which, in the United States of America, covers a defined population of members although it may be based on a major hospital and rarely provides all the care for a geographically defined population. These jurisdictions have to relate to a second type of bureaucracy – the institution that provides care, for example, a hospital or a mental health trust or a primary care team, and the relationship between the two is usually mediated by a contract. The institutions themselves relate to a third type of organisation, the profession – nursing, medicine or physiotherapy, for example – and each profession has a bureaucracy responsible for education, licensing and revalidation.

Managing population healthcare

Muir Gray, Erica Pitini, Thomas Kelley and Neil Bacon Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK Better Value Healthcare, 18-24 Middle Way, Oxford OX2 8JQ, UK International Consortium for Health Outcome Measurement,1 Eversholt Street, London NW1 2DN, UK iwantgreatcare, Unit 2 Manor Farm, Barns Witney Road, Finstock, Chipping Norton, Oxfordshire OX7 3DG, UK Corresponding author: Muir Gray. Email: muir.gray@medknox.net

Population healthcare: a new clinical responsibility.

Before 1948, Public Health doctors were population doctors and clinicians were responsible for the patients who consulted them or had been referred to them. After 1948, the situation changed because the whole population was covered by the NHS with clearly defined responsibilities for Scotland, Wales and Northern Ireland, and in England the 14 Regional Hospital Boards had a clearly defined population. General practitioners too suddenly became population doctors each with a list of 2000 patients. The hospital doctors were still responsible for dealing with the patients who were referred to them by general practitioners but in the early days of the NHS each district general hospital, and each teaching hospital too, had a clear sense of relationship to a population. In the era before the motorcar, people knew that Derby Royal Infirmary looked after most of Derbyshire but there came a point towards the North when people were referred to Chesterfield. People knew that the Radcliffe Infirmary in Oxford looked after most of Oxfordshire with the Horton Hospital in Banbury looking after North Oxfordshire and a little bit of Warwickshire and with some parts of Oxfordshire beyond Henley looking to Reading and the Royal Berkshire Hospital. When there is a relatively small number of consultants, two per specialty was the ‘Noah’s Ark principle’ of the time, and a limited number of general practitioners, all of them full-time, relationships developed between generalists and specialists. Furthermore, in the era before car parking became one of the major problems for every hospital, it was feasible to arrange regular lunchtime sessions in which the consultants from one specialty could meet with a large proportion of the GPs. So the hospitals had a clear sense of population until the market was introduced. The introduction of the purchaser/provider split, as it was called with the expectation that hospitals would compete with one another to attract patients, significantly weakened the relationship between specialists and the population they served and other initiatives such as the choose and book scheme combined with factors such as the growing number of specialists and general practitioners and the increasing proportion of both who were part-time has led to a significant breakdown between hospitals and the populations they serve. This has been a problem, and it is of particular importance as we look to an era in which need and demand will increase faster than resources, an era in which we will have to significantly increase the value that we derive from the resources available. Consider the questions that cannot be answered at present, questions such as is care for people with asthma better in Somerset or Devon or is care for people with epilepsy better in Liverpool or Manchester? One reason for this is that we have focused on measuring the quality of care for patients who have been referred to a service and not the outcome for those patients, or even more important, the outcomes for all the people in need in the population. Lowquality care is of low value but high-quality care is not necessarily of high value, and there is a need to broaden the leadership and management focus from the four activities that have dominated the service provision and professional practice for the last 20 years, namely prevention, evidence-based decisionmaking, quality improvement and cost reduction. All of these remain vitally important, but after 50 years of amazing progress in clinical care, every society on earth still faces three problems. The first is unwarranted variation in access, quality, cost and outcome, which reveals the other two. One, overuse of lower value interventions, which always leads to waste and often results in patient harm, even when the quality of care is high. The other is underuse of higher-value interventions, which leads to failure to prevent and treat disease effectively, and is often aggravated by inequity. What is needed therefore is to shift the focus from quality to value, and there are two aspects of value from a population perspective. The first is allocative value, determined by how the assets are distributed to

Public health leadership: creating the culture for the twenty-first century

Ludwig Wittgenstein said that almost all arguments were due to a failure to agree on the meanings of the terms being used. This certainly applies in the health service where discussions roam aimlessly over topics such as efficiency or equity or quality when it is quite obvious that all those involved are using a term with a different meaning. Where a term has a relatively sharply defined, technical, meaning, such as meta-analysis, its management is relatively straightforward, but as a term becomes more widely used, it acquires more meanings and reaches a point where it may cause more confusion than clarity; the term ‘systematic review’, for example, is now no longer as clear as it once was. There is no term in modern management with as many meanings as ‘leadership’, and some examples of the definitions collected in the Knowledge Into Action Glossary are shown below.

Personalised healthcare and population healthcare

Personalised or individualised healthcare and population healthcare are two sides of one coin. It follows that those responsible for developing population healthcare cannot ignore the individual. The first reason we cannot separate the individual from the population is that everyone involved in managing health services has an ethical duty to think of the individual. This principle was first enunciated in 1789 by Jeremy Bentham in his classic book An Introduction to the Principles of Morals and Legislation, in which he wrote ‘It is in vain to talk of the interests of the community without understanding what is the interest of the individual’. The second reason is that the value for each individual changes just like the value for the population as the investment in a service increases so people who make decisions about populations, for example to increase investment in a particular service change the nature of the clinical decisions made by individual clinicians and patients too. In Explorations in Quality Assessment and Monitoring, Donabedian described not only the concept of structure, process and outcome but also his ‘unifying model of benefit, risk and cost’. The power of this model is that it quantifies for the first time the relationship between resources invested in healthcare and the amount of value obtained from that level of investment. Donabedian showed that as healthcare resources are increased, benefit increases initially, but the increase then flattens off, illustrating what some people have called the law of diminishing returns. Importantly – and this is often overlooked – the amount of harm done does not diminish as resources invested. For each unit increase in resource, there is a unit increase in the number of people treated and consequently a unit increase in the amount of harm done. In fact, there may be a progressive increase in the amount of harm done if, with each unit increase in the availability of care, patients who are less fit and more at risk of harm are covered by the service. It is important to emphasise that the harm described in Donabedian’s model is not the result of medical errors or safety problems. Rather, harm occurs in all health services, even those that are of the highest quality, as an inevitable consequence of the risks associated with the act of interventions such as X-rays, drugs and anaesthetics. As a consequence, there may come a point at which the investment of additional resources will lead to a reduction in the net benefit, calculated by subtracting the harm from the benefit, and there comes a point beyond which additional investment reduces the value derived from the resources. He called this the point of optimality (Figure 1). There is another equally important reason why personalised care has to be considered to be the flip side of population healthcare. That is, as the value changes for the population as a whole, for example when more resources are put into a particular service such as cataract replacement or chemotherapy, the level of need of the average individual patient treated changes as less severely affected patients are deemed to be eligible. Thus, the clinical decision also changes as the investment of resources increase with a different balance of benefit and harm, as shown in Figure 2. Figure 2 also illustrates how two different communities of practice describe the changing relationship with different languages. To clinicians the decisions and interventions range from ‘necessary’ to ‘futile’, with ‘appropriate’ and ‘inappropriate’ in between. To people responsible for populations, the language is different, from ‘higher value’ at one extreme through ‘lower value’, ‘no value’, all the way to ‘negative value’, where the service does more harm than good. Thus, as we increase the amount of healthcare resources given to the population, we reduce the value to the population as a whole. We also affect the potential value to the individual with the balance of benefit to harm for each individual offered Journal of the Royal Society of Medicine; 0(0) 1–6

Equity and Value in ‘Precision Medicine’

Precision medicine carries huge potential in the treatment of many diseases, particularly those with high-penetrance monogenic underpinnings. However, precision medicine through genomic technologies also has ethical implications. We will define allocative, personal, and technical value (‘triple value’) in healthcare and how this relates to equity. Equity is here taken to be implicit in the concept of triple value in countries that have publicly funded healthcare systems. It will be argued that precision medicine risks concentrating resources to those that already experience greater access to healthcare and power in society, nationally as well as globally. Healthcare payers, clinicians, and patients must all be involved in optimising the potential of precision medicine, without reducing equity. Throughout, the discussion will refer to the NHS RightCare Programme, which is a national initiative aiming to improve value and equity in the context of NHS England.

Population healthcare: designing population-based systems:

The right structure is useful for simple tasks, but most health and healthcare issues are complex, where complexity is defined as ‘the dynamic state between order and chaos’. This means there is no linear relationship between input and output, but that their relationship is unpredictable; the carefully planned input may not lead to the desired output, and unintended consequences abound. Some healthcare problems are managed in a relatively orderly way. The young man who fractures his anklebone playing football will usually reach the right service quickly, receive a standardised treatment and recover without complications. Some populations, for example older people with frailty, have conditions whose care lies closer to the opposite end of the spectrum from order to chaos. As mentioned, most healthcare problems are complex, but exactly how complex they are will depend on the given condition. The solution to the problem of complexity is not more regulation, inspection or more detailed contracts, but rather the development of complex adaptive systems. These are defined by Sidhar Rihani as