spotlight

Value-based healthcare - a panacea or a pipedream? There is growing momentum globally around the theory of value-based healthcare and its contribution to developing better and more sustainable healthcare systems around the world. Described by Professors Porter and Teisberg from Harvard Business School, it has been billed in the US as the theory to save healthcare from the excesses of 'fee for service' in insurance-based funding systems, but can it really achieve its aims of better outcomes at lower cost and can it be effectively translated to other systems around the world? Overall I am a fan of looking at healthcare through this lens but there are complications with its application and delivery which it is important to point out. The theory is comprised of six pillars : 1. Outcome measurement - outcome measurement that matters to patients. Here the work of the International Consortium for Healthcare Outcomes Measurement ( ICHOM ) is a useful reference. 2. Cost measur...

Data and informatics for value-based healthcare - a mountain to climb? Introduction Value-based healthcare is gaining popularity as an approach to increase sustainability in healthcare. It has its critics, possibly because its roots are in a health system where part of the drive for a hospital to improve outcomes is to increase market share by being the best at what you do. This is not really a solution for improving population health and does not translate well to publicly-funded healthcare systems such as the NHS. However, when we put aside dogma about how we would wish to fund healthcare, value-based healthcare provides us with a very useful set of tools with which to tackle some of the fundamental problems of sustainability in delivering high quality care. What is value? Defined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best p...

Measuring patient-reported outcomes really matters Writing in the NEJM earlier this year, Ethan Basch summarises the findings of his paper 'Patient-reported outcomes - harnessing patients' voices to improve care' as this: 'Recording patient-reported outcomes electronically in real time and allowing clinicians to review longitudinal PRO reports can improve patients' quality of life, enhance patient–clinician communication, reduce emergency department utilization, and lengthen survival'. So what is a patient-reported outcome? We can think of it as a milestone or endpoint as a result of healthcare that comes entirely from the perspective of the person receiving that care. They are measured using validated questionnaires which may focus on pain, quality of life, wellbeing and ability to perform activities of daily living.  PROMs are not new and have typically been used to assess the effectiveness and cost effectiveness of surgical procedures such as joint rep...

                          Value-based healthcare is sexy A few days ago I was reminded yet again of the importance of words and how the way we use language has the ability to enthuse people....or switch them off entirely. I had been asked to speak on the topic of value-based healthcare at a respiratory study day hosted by the British Lung Foundation. Why? Well a local value-based healthcare project had resulted in significant investment in pulmonary rehabilitation and the ability to join this up with further community interventions to support people living with Chronic Obstructive Pulmonary Disease earlier in the course of their illness. The participants in this project had therefore become evangelists for this way of working across programmes of healthcare and felt it should be discussed. It didn't look promising. I had the last slot of the day, the coffee...

Mandatory peer review of GP referrals - why this gets my goat I see that referral management through peer review of referrals is doing the rounds again as the NHSE panacea for managing demand into secondary care. It is of course a well-intentioned attempt to ensure that we are using scant NHS resources wisely , but in the face of growing unmet needs in the community I am fairly certain that it will be an expensively futile endeavour. Here is my ham-fisted attempt to explain why I believe this is so. Referral for consultant opinion is one of the few tools a general practitioner has to help people get better from their symptoms and the reasons for referral can be divided up in a pretty straightforward way: 1. The patient has unexplained symptoms or there is diagnostic uncertainty. Medical diagnoses are often difficult to make and do not come neatly wrapped in boxes. Clinical diagnoses (i.e. those made without a diagnostic test) are often particularly difficul...

What really matters in healthcare? Two of my dearest friends are living with metastatic cancer. We talk as close friends do and they have both often asked me how to have a conversation with the healthcare professionals looking after them so that they can make the decisions they need to make to live as well as they can for as long as they can. Talking to my friends in this way has brought the issue of shared decision making up close and personal in a way I have not previously experienced. As a GP I like to think that I am always considering the needs and goals of the people under my care and I am sure I am no different to any other clinician. However, despite all of our best intentions we can get it wrong and this is because our perspective is so very different from that of our patients. We are focused on clinical outcomes...has the tumour reduced on the scan, what is the average time to progression for a given treatment? My mates want to know this too...but also if th...

T he Prudent Healthcare Blogs - Variety is not the spice Principle four - Reduce inappropriate variation through evidence-based approaches I have tweeted a few times already about the peculiarities of language and the power words have to please and offend. I therefore now confess that I am offended by the word 'inappropriate' as it appears in the fourth prudent principle. I have tried to think about why that should be and have come to the conclusion that 'inappropriate' somehow implies a transgression, in this case perhaps by a well meaning healthcare professional. I take exception to that for some reason - unwarranted feels better and is in any case more true to the original definition. Unwarranted variation is a term coined by Dr John Wennberg, founder of the Centre for Evaluative Clinical Services at Dartmouth Medical School in the United States. He defined it as variation in healthcare delivery that cannot be explained by illness, medical need or evidenc...