Dr Lawrence Goldberg explores how clinicians and clinical commissioners can take forward value-based approaches in partnership with patients
Delivering value in healthcare, that is, achieving the best patient-defined outcomes for the expended resources, is key to sustainable services in the 21st century.
Delivering value in healthcare … is key to sustainable services in the 21st century
Understanding value requires:
- a redefinition of meaningful outcomes from healthcare interventions: prevention, diagnostics, and treatments
- more active patient participation in deciding on their best treatment through shared decision making
- a better health economic understanding of the full pathway costs of the different treatment options available.
Changing our focus to delivering value requires an adaptation in the way clinicians, patients, and commissioners think about, and make, health-related decisions. The changes in culture, mindset, and practice require support, training, new outcome measures, better health economics, and the promotion of shared decision making.
Recognising the low level of awareness among healthcare professionals of the value-based approach, the South East Clinical Senate undertook to enhance understanding of its importance and benefits. It has produced a briefing document for clinicians and clinical commissioners on how they can take the approach forward in partnership with their patients, populations, and managerial colleagues,1 which is summarised in this article.
The demand for healthcare in England, and across the world, is increasing inexorably and needs to be delivered in a finite NHS budget at whatever level that budget is set. Therefore, all who provide, commission, and manage healthcare must ensure the available resources are used to achieve the best outcomes for patients and populations. The NHS Constitution states: ‘The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources,’ 2 while the General Medical Council has published specific guidance for doctors.3
The relationship between outcomes and resources expended should be fundamental in determining the health services and care we should and can provide; this relationship is defined as ‘value’. The concept of value in healthcare was pioneered by Michael Porter and Robert Kaplan.4 It is now the subject of intense focus in the NHS, thanks to the vision and advocacy of Professor Sir Muir Gray, as a new paradigm for how we think about healthcare delivery at a patient and population level.
Value in healthcare
See Box 1 for how value can be represented. While at first glance this information appears to be an equation, it is more a representation of the key relationship between the three components of value, outcomes, and resources.
Box 1: Measuring the value of an intervention
In this context, ‘outcomes’ refers to the net, long-term impact of the proposed intervention—an investigation, treatment, or preventative measure—on the patient or the population. It takes account of the potential benefits, risks, and adverse events associated with the intervention, and the effects on functional status and wellbeing.
‘Resources’ refers to the totality of resources required to deliver the intervention across community, hospital, and social care, not just the provider tariff or medication costs. It should also take account of the impact of unnecessary, duplicate, and fragmented care (‘waste’); the costs of adverse events; the clinical time expended; the environmental impact; and opportunity costs.
The relationship between increasing the resources applied to a healthcare intervention and the value obtained is summarised in Figure 1. When considering patients or populations for specific interventions, the criteria for interventions should be referenced against the ‘point of optimality’ beyond which value decreases. Using this approach, healthcare professionals and clinical commissioners can evaluate the clinical impact and cost effectiveness of the different types of care they could offer, and determine what treatments should be prioritised if of higher value, or restricted or withdrawn if of lower or no value.
Figure 1: The relationship between increasing resources and benefit, harm, and value5
Gray M. A culture of stewardship: the responsibility of NHS leaders to deliver better value healthcare. London: NHS Confederation and Academy of Medical Royal Colleges, 2015. Available at: www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/NHS%20DoV%20Briefing%20Document_WEB.pdf (Reproduced with permission)
Value for individual patients or the population
The value concept can be applied to both the care of individual patients and to the commissioning and delivery of care to populations; while the conclusions may be different and potentially conflicting when applied to each, the principles for determining value are the same.
For example, for an individual patient there may be a net overall benefit to them from a high cost treatment. However, at a population level, a greater value may be obtained by spending the available resources in other ways, including prevention, and restricting access to the high cost treatment (such as high cost medicines for rare conditions) even if it is evidence based. This is an unavoidable and inherent tension for clinicians and managers in the NHS, but it needs to be explicitly recognised by all those who are commissioning and delivering clinical services.
Value depends on outcomes that improve people’s lives
When determining the value of the healthcare we provide, we should focus on what makes a difference to patients’ lives.
When determining the value of the healthcare we provide, we should focus on what makes a difference to patients’ lives
Outcome measures are, therefore, best described and defined together with patients (co‑produced), rather than using those that are process based or use surrogate measures such as clinical indicators. The need for such outcome definitions and data is increasingly recognised. The King’s Fund reviewed the benefits of putting patient-reported outcome measures (PROMs) at the heart of NHS decision making.6 An example from orthopaedics shows the benefits of using PROMs to monitor the impact of treatments on patients’ self-reported functional status.7
The development of condition-specific patient outcome measures requires clinical leadership undertaken in partnership with patients and supported by an evidence base. The International Consortium for Health Outcomes Measurement (ICHOM) provides international leadership on this work and has already published standard sets covering nearly 50% of the global disease burden.8 The medical royal colleges, NICE, and specialist societies are increasingly focused on developing such metrics. A succinct and powerful case for the development and international standardisation of outcome measures relevant to patients has recently been made by Porter and colleagues.9
Shared decision making and the importance of understanding patient preferences
Making the right decisions for patients is a collaborative process in which patients and clinicians decide on treatment and care together. It takes into account the best evidence available and, critically, patients’ values and preferences. This process has been termed ‘shared decision making’ (SDM).10 Together they share:
- the clinician’s expertise—such as on treatment, care, or support options; evidence, risks, and benefits
- what patients know best: their preferences, personal circumstances, goals, values, and beliefs.
Patient preferences, however, often differ from what doctors or even family members think they want. When patients are well informed and are asked to consider the outcomes that matter to them, they make different choices about their treatment. How they decide also depends on how the information is presented.11–15 The risk of misdiagnosing patient preference relates to both clinician and patient knowledge. Addressing so-called ‘preference misdiagnosis’ can result in choosing less complex treatments, better outcomes as described by patients, and less expenditure on procedures that patients may not want.
Key to SDM is evidence-based information on the benefits and risks of the potential range of treatments available, presented in an unbiased way that is easily understandable to the lay person: much more work is required in this area. Where possible these SDM discussions should take place in primary care, but for a discussion of more specialist treatment options they may also take place after referral. Of note, NICE has produced a series of decision support tools for patients on a range of conditions.16
Shared decision making may involve longer or several consultations, but as the final decisions made should result in better value care, consultation resources should be targeted accordingly. The need for more time spent with the patient can be mitigated by the provision of printed or online decision aids and by asking non‑medical staff to initiate or progress the discussions.
Of course, some patients may wish to take a more passive role and have decisions made for them. In these situations, involving carers and family in decision making, with a patient’s agreement, can help to ensure the best decisions are made.
Clinicians should be aware of the many factors that influence the decision-making process between them and patients, and that poor decisions will likely result in lower-value care.17 Examples are shown in Box 2.
Box 2: Patients’ and clinicians’ beliefs and behaviours that contribute to poor decision making1
- Medicine is based strictly on science
- Testing, especially high-tech testing, is accurate (poor understanding of error rates and other limits in tests and treatments)
- Unquestioning trust in doctor’s expertise
- Fear of offending clinician by asking questions
- ‘My neighbour/niece/co-worker had this done, and they had a good outcome’
- Demand induced by providers and other commercial actors in the healthcare industry
- More care is better care, especially in a system without continuity of care, whereby the measure of caring is by doing rather than by it being present
- Misplaced assumptions and mistrust about financial motives of providers
- Anxiety about uncertainty and adverse outcomes.
- Evidence contradicts training or practice experience
- Clinician innumeracy
- Over-reliance on pathophysiological and anatomical reasoning and faith in surrogate outcomes
- A so-called better-to-know bias that might not be warranted
- Improper weighing of relative risk versus absolute risk
- Regret of omission overriding regret of commission
- Therapeutic or technological enthusiasm
- Recent adverse outcome, rear-view mirror bias (a manifestation of the affect heuristic)
- Defensive medicine-avoiding litigation.
Adapted from: Saini V, Garcia-Armesto S, Klemperer D et al. Drivers of poor medical care. Lancet 2017; 390 (10090): 178–190. (Reproduced with permission)
Delivering appropriate and efficient care
Value involves using available resources to best effect and avoiding clinical activities that add little benefit to patients or populations. There is increasing awareness of overdiagnosis and overtreatment in a number of clinical areas, brought to prominence by:
- the Choosing Wisely UK programme18
- BMJ’s Too Much Medicine
- the King’s Fund’s Better Value in the NHS initiatives19
- the Lancet Right Care series20
- NICE’s Do Not Do recommendations.21
NB Some of the ways these problems can be addressed have been well summarised in a recent BMJ article.22
Value also requires the avoidance of that unwarranted variation in outcomes (such as that identified in NHS RightCare analyses),23 which if addressed would increase value. It also requires efficient and lean services for patients using the work of the Carter Review24 and the Getting It Right First Time (GIRFT) programme,25 among other approaches.
Evolving methodologies for assessing value in healthcare
A health economic approach is necessary if the values of different interventions are to be compared. This requires data on both meaningful patient outcomes and the full pathway costs of interventions.26 Robert Kaplan outlined approaches to determining costs and value in an important report for the Healthcare Financial Management Association.27 The Best Possible Value initiative, in the NHS’s Future-Focused Finance programme, is starting to develop methodologies for comparing value.28
Understanding the concept of value in healthcare, and providing it, are essential for a sustainable NHS that delivers the best outcomes for patients and populations within available resources. This requires a re‑definition of outcomes that matter to patients’ quality of life, the more active involvement of informed patients in deciding their treatment through the process of shared decision making, and a much better understanding of the full pathway costs and resources required for the different treatment options for different conditions.
Understanding the concept of value in healthcare, and providing it, are essential for a sustainable NHS
Value for individual patients and populations is often but not always aligned, and the tension between the two needs to be explicitly recognised in deciding on which health interventions are commissioned.
To help develop and embed value-based healthcare in local health systems, the South East Clinical Senate report on value produced a range of recommendations for clinicians and commissioners to consider, and these are summarised in Box 3.
Box 3. Recommendations
- Professional bodies, NICE, clinicians, clinical commissioners, and patient groups should expand their work in co-producing meaningful and relevant outcome measures to support value-based decisions using the International Consortium for Health Outcomes Measurement standard sets8 as the starting point.
- Clinicians, patients, and commissioners should work together to determine the relative value of treatments and interventions at both a patient and population level, by agreeing then using relevant outcome measures and determining comparative whole pathways costs.
- Health systems, such as STPs or more local place-based partnerships, should undertake a clinically led programme of work to identify the causes of any significant variation in patient outcomes and clinical practice, such as those identified by NHS RightCare data23 and the Getting It Right First Time programme.25 They should then focus on those that, if addressed, could have the greatest impact on improving value. The various screening and disease prevention strategies should be included in this evaluation at a national level.
- Clinicians require training in shared decision making and the appropriate communication skills. Organisations should make this part of mandatory training to help embed a culture and the supporting competencies. Available resources include the training module on Health Education England’s e-Learning for Healthcare website.29 Medical schools for undergraduates, and medical royal colleges for trainees, should include the concept of value and the benefits of shared decision making in their curricula.
- Advice and tools are available to help organisations embed shared decision making, such as KPMG’s review,30 the King’s Fund’s overview of patient preferences,15 and tools developed by the Advancing Quality Alliance and NHS RightCare.31
- Healthcare professionals should ensure that they and their patients have access to relevant, accurate, comprehensible, and balanced information on the potential outcomes (benefits and harms) of their treatment choices. This information should include local audit data and published results of complication rates. In this way patients are given deserved autonomy in making decisions about their healthcare that are consistent with their aspirations and beliefs.
- Commissioners and clinicians should aim to enhance patients’ confidence and ability to make more active decisions about their healthcare. The 10 key actions described in the Health Foundation and Nesta’s Realising the Value report32 are recommended.
- Health systems should review the additional consultation time required for shared decision making, how doctors can be supported in this activity by other healthcare professionals and decision support tools, and its potential cost effectiveness from reducing referrals for specialist procedures if fully informed patients choose less costly alternatives.
- The public needs to be informed about the importance of providing value in healthcare, and their role in supporting this through shared decision making. This should be promoted at local, regional, and national levels. The NHS should develop a clear and consistent message.
STPs=sustainability and transformation partnerships
- South East Clinical Senate. Emphasising quality, delivering value: a briefing for clinicians in Kent, Surrey and Sussex on achieving the best patient outcomes within available resources. Surrey: South East Clinical Senate, 2017. Available at: www.secsenate.nhs.uk/news/emphasing-quality-delivering-value
- Department of Health. The NHS Constitution, principle 6. London: DH, 2015. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf
- General Medical Council. Leadership and management for all doctors, paragraphs 79–80. Manchester: GMC, 2012. Available at: www.gmc-uk.org/static/documents/content/Leadership_and_management_for_all_doctors_-_English_1015.pdf
- Porter M. What is value in health care? NEJM 2010; 363 (26): 2477–2481.
- Gray M. A culture of stewardship: the responsibility of NHS leaders to deliver better value healthcare. London: NHS Confederation and Academy of Medical Royal Colleges, 2015. Available at:
- Devlin N, Appleby J. Getting the most out of PROMs. London: The King’s Fund, 2010. Available at: www.kingsfund.org.uk/sites/files/kf/Getting-the-most-out-of-PROMs-Nancy-Devlin-John-Appleby-Kings-Fund-March-2010.pdf
- Baumhauer J, Bozic K. Value-based healthcare: patient-reported outcomes in clinical decision making. Clin Orthop Relat Res 2016; 474 (6): 1375–1378.
- International Consortium for Health Outcomes Measurement. Our standard sets. www.ichom.org/medical-conditions (accessed 13 October 2017).
- Porter M, Larsson S, Lee T. Standardizing patient outcomes measurement. NEJM 2016; 374 (6): 504–506.
- NHS England. Shared decision making.
www.england.nhs.uk/ourwork/pe/sdm (accessed 13 October 2017).
- Lee C, Dominik R, Levin C et al. Development of instruments to measure the quality of breast cancer treatment decisions. Health Expect 2010; 13 (3): 258–272.
- Kennedy A, Sculpher M, Coulter A et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA 2002; 288 (21): 2701–2708.
- Rothberg M, Sivalingam S, Ashraf J et al. Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med 2010; 153 (5): 307–313.
- Misselbrook D, Armstrong D. Patients’ responses to risk information about the benefits of treating hypertension. Br J Gen Practice 2001; 51 (465): 276–279.
- Mulley A, Trimble C, Elwyn G. Patients’ preferences matter: stop the silent misdiagnosis. London: The King’s Fund, 2012. Available at: www.kingsfund.org.uk/publications/patients-preferences-matter
- NICE. Patient decision aids. https://www.evidence.nhs.uk/search?q=patient+decision+aid+rightcare (accessed 13 October 2017).
- Saini V, Garcia-Armesto S, Klemperer D et al. Drivers of poor medical care. Lancet 2017; 390 (10090): 178–190.
- Choosing Wisely UK. Recommendations. www.choosingwisely.co.uk/i-am-a-clinician/recommendations/#1476656741023-851ffdd6-39ae (accessed 13 October 2017).
- King’s Fund. Practical approaches to delivering better value in the NHS.
www.kingsfund.org.uk/projects/practical-value-nhs (accessed 13 October 2017).
- Lancet. Right care. www.thelancet.com/series/right-care (accessed 13 October 2017).
- NICE. Browse do not do recommendations by topic. www.nice.org.uk/donotdo/conditions-and-diseases (accessed 13 October 2017).
- Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017; 358: j3879.
- NHS England. NHS RightCare Intelligence products. Available at: www.england.nhs.uk/rightcare/products/ (accessed 30 October 2017).
- Department of Health. Operational productivity and performance in English NHS acute hospitals: unwarranted variations—an independent report for the Department of Health by Lord Carter of Coles. London: DH, 2015. Available at:
- GIRFT: Getting it Right First Time programme. Available at: gettingitrightfirsttime.co.uk (accessed 30 October 2017).
- World Economic Forum. Value in healthcare: laying the foundation for health system transformation. Geneva: World Economic Forum, 2017. Available at: www3.weforum.org/docs/WEF_Insight_Report_Value_Healthcare_Laying_Foundation.pdf
- Kaplan R. Costing and the pursuit of value in healthcare. Bristol: Healthcare Financial Management Association, 2015. Available at: www.hfma.org.uk/docs/default-source/our-networks/healthcare-costing-for-value-institute/institute-publications/costing-and-the-pursuit-of-value-in-healthcare
- Best Possible Value website. Available at: bpv.futurefocusedfinance.nhs.uk (accessed 30 October 2017).
- Health Education England. Shared decision making. www.e-lfh.org.uk/programmes/shared-decision-making/how-to-access/ (accessed 13 October 2017).
- Britnell M, Ambres C, Thomas H. What works: creating new value with patients, caregivers and communities. Amsterdam: KPMG International, 2016. Available at: assets.kpmg.com/content/dam/kpmg/pdf/2016/04/creating-new-value-with-patients.pdf
- Advancing Quality Alliance. Your health—your decision. Evaluation & output report of the AQuA workstream within the national shared decision making programme. Salford: AQuA, 2012. Available at: www.aquanw.nhs.uk/resources/shared-decision-making/Your-Health-Your-Decision-Evaluation-Report.pdf
- Finnis A, Khan H, Ejbye J et al. Realising the value. London: The Health Foundation and Nesta, 2016. Available at: www.health.org.uk/sites/health/files/RtVRealisingTheValue10KeyActions.pdf