The document discusses increasing value in healthcare systems through a "Triple Value Healthcare" approach. It proposes focusing on personal value for individuals, population value for given populations, and technical value through optimizing outcomes and resource use. Key strategies include providing full information to patients, shifting resources from overused to underused areas, developing population-based systems and networks, and creating a culture of stewardship. The goal is to improve outcomes while making the best use of limited resources.
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THE PRESENT
Period of high
dependency
on other people
THE FUTURE
HEALTHSPAN
LIFESPAN
LONGER HEALTHSPAN
Shorter period of high
dependency
on other people
NO SIGNIFICANT INCREASE IN LIFESPAN
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Need and demand will increase by about 20% in the next decade and resources will not
Resources
Need + Demand
Why has value become the number one focus for health
services world wide?
• Ageing
• New technology
• Increasing intensity of
clinical practice
Need
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We have had 2 healthcare revolutions, with amazing impact
Antibiotics
MRI & CT
Coronary artery bypass graft
surgery
Hip & knee replacement
Chemotherapy
Radiotherapy
Randomised controlled trials
Systematic reviews
The Second has been the
technological revolution supported
by 50 years of increased investment
& 20 years of evidence based
medicine, quality and safety
improvement eg
The First was the public health
revolution
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Indicators where we don’t know the ‘right’ rate
After 50 years of progress all societies still face
three massive problems.
The first is unwarranted variation in healthcare
i.e. “Variation in utilization of health care
services that cannot be explained by variation in
patient need or patient preferences.” Jack
Wennberg
Variation reveals the other two problems
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The first problem is
underuse:
prevention of
complications
Range: 30.4%-76.4%
Degree of variation: 2.5-fold
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underuse of high value interventions may also result in
inequity
0
10
20
30
40
50
60
70
80
90
100
Knee Hip
Comparison of NHS joint replacement in Oxfordshire 2012
Wealthiest ward =100
Wealthiest Poorest
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The second problem is overuse which always results in
waste and may also cause harm
Benefit
Resources
Underuse
EffectSize
Overuse
⇒ always wastes
resources
⇒ can cause
harm
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Quality and safety programmes bring some
improvement in the point of optimality
Benefit
Resources
Underuse
Benefit - Harm
EffectSize
= with quality
and safety
OverusePoint of Optimality
Harm
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We have had 2 healthcare revolutions, with amazing impact
Antibiotics
MRI & CT
Coronary artery bypass graft
surgery
Hip & knee replacement
Cataract
Chemotherapy
Over treatment in the last
year of life
Examples of overuse which are
regularly raised in professional and
public meetings in the uk
The First was the public health
revolution
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The value of country comparisons
Range: 53.9-190.4 per 100,000
Fold-difference: 3.5-fold
Reasons for variation:
• Higher rates of underlying disease in Black
populations
• Lack of pre-dialysis in some people
• High proportion of for-profit dialysis providers
in combination with unrestricted funding for
RRT by Medicare in USA
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Why we need value
In the next decade need and demand will increase by at least 20 % so what can we
do?
We need to continue to:
1. Prevent disease, disability, dementia and frailty
to reduce need
2. Improve outcome by provide only cost-effective, evidence based interventions
3. Improve outcome by increasing quality and safety of process
4. Increase productivity by reducing cost
These measures reduce need and improve efficiency, but they will not bridge the
gap, so we need to focus on value.
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Triple Value
Personal value: improving the outcomes that matter to an individual for a given
investment of resource used by the health system and by the individual and
their family
Population value: investing resources more wisely within a health system to
optimise the outcomes for the given population for which the health system is
responsible
Technical value: optimising the use of resources to get the best possible
outcomes for people being treated within a given pathway or process
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• Increase personal value ensure that every individual receives high personal value by
providing people with full information about the risks and benefits of the
intervention being offered
• Shift resource from budgets where there is evidence of overuse or lower value to
budgets for populations in which there is evidence of underuse and inequity
• Develop population based systems and networks
• Create a culture of stewardship
The New Agenda – the Oxford Centre for Triple Value
Healthcare Method Of Increasing Value
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We are now in the third healthcare revolution
The First The Second The Third
• Antibiotics
• MRI
• CT
• Ultrasound
• Stents
• Hip and knee replacement
• Chemotherapy
• Radiotherapy
• RCTs
• Systematic reviews
Citizens
KnowledgeSmartphone
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Decision based on the
likelihood that this
intervention will
achieve the outcomes
that matter to this
individual
Evidence for the cost
effectiveness of the
intervention
Clinical condition of
this particular
individual
Outcome that matters
to this individual
Individual’s report on the degree to which the
intervention has achieved the outcome that mattered
This is real precision medicine
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Providing people with full information about the risks and benefits of the intervention
being offered – it is the ethical thing to do. Shared decision support tools are plentiful
And all the evidence is that:
✓It makes it more likely that the right care is given to the right patient
✓Individuals are more parsimonious than clinicians
✓Allowing patients to make the decision in itself improves the outcome (i.e. it is an
effective intervention in its own right)
Elwyn Glyn, Laitner Steve, Coulter Angela, Walker Emma, Watson Paul, Thomson Richard et al. Implementing shared decision making in
the NHS BMJ 2010; 341 :c5146
Decision support is one proven, under used, means
of increasing personal value
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• Increase personal value ensure that every individual receives high personal value by
providing people with full information about the risks and benefits of the intervention
being offered
• Shift resource from budgets where there is evidence of overuse or lower value to
budgets for populations in which there is evidence of underuse and inequity
• Develop population based systems and networks
• Create a culture of stewardship
The Triple Value Healthcare Method Of Increasing Value For
Populations
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Many people have more than one
problem ; they have complex needs.
GP’s are skilled in managing complexity
but when one of the problems becomes
complicated the Generalist needs
Specialist help
Cancers
Respiratory
Gastro-
intestinal
Mental
Health
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We need only to be reasonable
“Accountability for reasonableness is the idea that the reasons or rationales for
important limit-setting decisions should be publicly available. In addition, these
reasons must be ones that ‘fair-minded’ people can agree are relevant to pursuing
appropriate patient care under necessary resource constraints
By ‘fair-minded’, we do not simply mean our friends or people who just happen to
agree with us. We mean people who in principle seek to cooperate with others on
terms they can justify to each other. Indeed, fair-minded people accept rules of the
game – or sometimes seek rule changes – that promote the game’s essential skills
and the excitement their use produces.”
Daniels, N. and Sabin, J.E. (2008) Setting Limits Fairly, Learning to Share Resources for Health. Oxford University
Press.
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• Increase personal value ensure that every individual receives high personal value by
providing people with full information about the risks and benefits of the intervention
being offered
• Shift resource from budgets where there is evidence of overuse or lower value to
budgets for populations in which there is evidence of underuse and inequity
• Develop population based systems and networks
• Create a culture of stewardship
The Triple Value Healthcare Method Of Increasing
Value For Populations
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Most health systems are built in 2D
Types
Of
Care
SELF CARE
INFORMAL CARE
e.g family
GENERALIST
(primary)
SPECIALIST
(secondary)
SUPER
SPECIALIST
Bureaucracies
HealthBoards
HealthImprovement
NHS24
Health&Social
CareDirectorate
NHSHealthScotland
…..
…..
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Types
Of
Care
SELF CARE
INFORMAL CARE
e.g family
GENERALIST
SPECIALIST
SUPER
SPECIALIST
Bureaucracies
When it comes to considering the people affected,
healthcare is really in 3D
Mental health problems
Frailty
Cancer
Eye problems
HealthBoards
Health
Improvement
NHS24
Health&Social
CareDirectorate
NHSHealthScotland
…..
…..
Populations
defined by need
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Is the care for people with, terms of the outcomes and taking into
account the resources invested, better in Kuopio or Vaasa?
Which network in Finland for people with Type 1 diabetes delivers the
best value in terms of both outcomes and the resources used ?
Is the care for people with in the last year of life better in Tampere or
Turku?
Is the care for people with depression in terms of the outcomes taking
into account the resources invested better in Oulu or Pori?
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At a national level questions such as those below could
also be addressed
Is the care for people with epilepsy better in terms of
the outcomes taking into account the resources
invested in Helsinki or Copenhagen or Edinburgh?
Is the care for people with rheumatoid arthritis better,
in terms of the outcomes and taking into account the
resources invested, in Wales or Finland or Lombardia?
43. OBJECTIVES FOR A SYSTEM FOR PEOPLE WITH ASTHMA
•To prevent asthma
•To diagnose asthma quickly and accurately
•To slow the process of the disease by effective and safe
treatment
•To help the individual afflicted adapt to the challenges
•To involve patients, both individually and collectively, in
their care
44. •To prevent asthma
•To diagnose asthma quickly and accurately
•To slow the process of the disease by effective and safe
treatment
•To help the individual afflicted adapt to the challenges
•To involve patients, both individually and collectively, in
their care
•To make the best use of resources
•To mitigate inequity
•To promote and support research
•To support the development of staff
•To report annually to the population served
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All people with
the condition who do
not need to see the
specialist service practice
healthcare supported by
generalists who are
themselves supported
by specialists
The right
People
receiving
the specialist
service
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• Increase personal value ensure that every individual receives high
personal value by providing people with full information about the
risks and benefits of the intervention being offered
• Shift resource from budgets where there is evidence of overuse or
lower value to budgets for populations in which there is evidence of
underuse and inequity
• Develop population based systems and networks
• Create a culture of stewardship; leadership shapes culture;
management works within that culture
The Triple Value Healthcare Method Of Increasing
Value For Populations
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Use new language
System is a set of activities with a common set of objectives and outcomes; and an
annual report. Systems can focus on symptoms, conditions or subgroups of the
population
Network is a set of individuals and organisations that deliver the system’s objectives
Pathway is the route patients usually follow through the network
Programme is a set of systems with a common knowledge base and a common
budget
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Stewardship is the most important word of all
“Doctors should embrace the values of
resource stewardship in their clinical
practice”
Stewardship is to hold something you do
not own in trust for future generations