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the paradigm is changing; the dominant focus for the next decade at least will be value, or to be precise triple value The Aim is triple value & greater equity • Allocative value, determined by how the assets are distributed to different sub groups in the population • Technical value, determined by how well resources are used for all the people in need in the population • Personalised value, determined by how well the decisions relate to the values of each individual If you want to see more please look at http://bettervaluehealthcare.weebly.com
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Progress in the last 40 years has been amazing but
all health services, everywhere, still face 5 major problems one of which is unwarranted variation which reveals the other four
• HARM, from overuse even when quality is high• WASTE OF RESOURCES through low value activity • INEQUITY, from underuse by groups in high need • FAILURE TO PREVENT DISEASE &DISABILITY
And new, additional, challenges are developing
• RISING EXPECTATIONS• INCREASING NEED• FINANCIAL CONSTRAINTS• CLIMATE CHANGE
Variation in utilization of health care services that cannot be explained by variation in patient illness or patient preferences.Jack Wennberg
More of the same is not the answer , not even better quality, safer, greener cheaper of the
same run by more tightly regulated and inspected bureaucracies
we need to design, plan and build a new paradigm to adapt to the challenge of
complexity – “the dynamic state between chaos and order” Kieran Sweeney (2006)
The Healthcare Archipelago
GENERAL MENTAL PRACTICE HEALTH
COMMUNITY HOSPITALSERVICES SERVICES
JURISDICTIONS INSTITUTIONS
PROFESSIONS
REGULATORS AND INSPECTORS
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• Is the service for people with seizures & epilepsy better in Adelaide than the service in Melbourne?
• Who is responsible for the pelvic pain service for people in North Adelaide?• How many liver disease service s are there in South Australia and how
many should there be?• Which service for frail elderly people in Auckland provides the best value?• How many services are there for people with MusculoSkeletal Disease in
South Australia, and which gives best value?• Is the variation in outcome for heart failure in the South Australia services
increasing or decreasing?• Who is responsible for publishing the Annual Report on care for people
with Parkinson’s disease in North Adelaide?• Is the service the people in our population with atrial fibrillation
below the minimal acceptable standard of high quality, ie in the top quartile in the middle of the range (a-b)
Population healthcare focuses primarily on populations defined by a common need
which may be a symptom such as breathlessness, a condition such as
arthritis or a common characteristic such as frailty in old age, not on institutions , or
specialties or technologies. Its aim is to maximise value and equity for those
populations and the individuals within them
Triple Value Agenda
Cancer
Respiratory
Gastro-intestinal
Between ProgrammeMarginal Analysis and reallocation is a Board responsibility with public involvement ; the aim is optimal allocation ie you cannot get more value by shifting a single £ from one budget to another
Allocative efficiency
Cancer
Respiratory
Gastro-intestinal
MentalHealth
Between ProgrammeMarginal Analysis and reallocation is a commissioner responsibility with public involvement
Cancers
Respiratory
Gastro-intestinal
MentalHealth
Many people have more than one problem ; GP’s are skilled in managing complexity
MedicallyUnexplainedPhysicalSymptoms
Homelesspeople
Children
Older People With fouror more diagnoses
Cancers
Respiratory
Gastro-instestinal
ObesityGastroIntestinal
Liver
Within Programme,Between SystemMarginal analysis is a clinician responsibility
Cancers
MSK
PorosisOA/Joints
RA
Respiratory
Triple Value Agenda
Technical Value (Efficiency) = Outcomes / Costs
Outcome= Benefit (EBM +Quality) – Harm (Safety )Costs (Money + time + Carbon)
Added value from doing things right (quality improvement)
Higher Value
HigherValue
High Value
Lower Value
Lower Value
THE INSTITUTIONAL APPROACH
After a certain level of investment, health gain
may start to decline Benefits
Investment of resources
Harms
Benefits - harm
Point of optimality
1. Reduce lower or negative value activities
Cancers
Respiratory
Gastro-instestinal
Apnoea
COPD (Chronic
Obstructive Pulmonary
Disease)
Asthma
Triple DrugTherapy
Rehabilitation
O2
Smoking cessation
Within SystemMarginal Analysis is a clinician responsibility with patient involvement
Cancers
MSK
PorosisOA/Joints
RA
MRI
Replacement
Arthro/washout
Respiratory
All people with the condition
People receiving the specialist service
People who would benefit most from the specialist service
3. See the right patients
Hellish Decisions in Healthcare
High Value Innovation +Disinvestment from
Lower Value Interventions
Triple Value Agenda
Evidence,
Derived from
the study of
groups of
patients
The values this patient
places on the problem that
matter most to them, and on
benefits & harms of the options
The clinical and social condition of this
patient; other diagnoses, risk factors
and their genetic profile
Choice Decision
Personalised and Patient Centred Care
“By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.”Source: Straus, S.E., Richardson, W.S., Glasziou, P., Haynes, R.B. Evidence-Based Medicine. (2000) How to practice and teach EBM. (3rd Edition). Elsevier Churchill Livingstone. (p.1).
After a certain level of investment the health gain may start to decline;
the point of optimality
Benefits
Investment of resources
Harms
Benefits - harm
As the rate of intervention in the population increases, the balance of benefit and harm
also changes for the individual patient
Necessary appropriate inappropriate futileHigh value Low value Negative Value
BENEFIT
HARM
LOW VALUE (BUREAUCRACY BASED CARE)
HIGH VALUE (PERSONALISED & POPULATION BASED)
Deliver Care through Integrated, Population-based Systems
Develop clinical focus on populations
Personalise Care & Decision -making
Change the Culture to a collaborative culture
DIGITAL KNOWLEDGE
The Healthcare Archipelago
GENERAL MENTAL PRACTICE HEALTH
COMMUNITY HOSPITALSERVICES SERVICES
Chaos…..….Complexity……...Order Person aged 87, 5 diagnoses8 prescriptions, cared for by Daughter with alcoholic husband
Man aged 23, Potts#Football
woman aged 45 invited for cervical screening
Man aged 67 with Dukes A colorectal ca.
Man aged 57 with Psychosis, drug dependence, and severe epilepsy
woman aged 73, webuser, with T2 Diabetes, STEMI, high blood pressure, homeopathy
woman aged 67 painful hip &mild depression
Complex Adaptive Systems
• “Certain nonlinear systems … are commonly described as being Complex, because their behavior is defined to a large extent by local interactions between their components. When such systems are capable of evolution they are also known as Complex Adaptive Systems.”
• Source: Rihani, S (2002) Complex Systems Theory and Development Practice. Understanding non-linear realities. Zed Books Ltd. (p.7).
SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST
SUPER SPECIALIST
This is an example of a national service set upas a system
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Hierarchy Network
LOW VALUE (BUREAUCRACY BASED CARE)
HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)
Deliver Care through Population-based Systems
Develop clinical focus on populations
How to achieve high value through Population and Personalised care
Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and providedevidence based, patient centred care, and to improve effectiveness, productivity and safety
Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit from the knowledge of her team
Dr Jones is given 1 day a week for Population Respiratory Health and the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources for
Working with Public Health to reduce smoking Network developmentQuality of patient informationProfessional development of generalists, and
pharmacists Production of the Annual Report of the service
She is keen to improve her performance from being 27th out of the 106 COPD services, and of greater importance, 6th out of the 23 services in the prosperous counties
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• Is the service for people with seizures & epilepsy better in Adelaide than the service in Melbourne?
• Who is responsible for the pelvic pain service for people in North Adelaide?• How many liver disease service s are there in South Australia and how
many should there be?• Which service for frail elderly people in Auckland provides the best value?• How many services are there for people with MusculoSkeletal Disease in
South Australia, and which gives best value?• Is the variation in outcome for heart failure in the South Australia services
increasing or decreasing?• Who is responsible for publishing the Annual Report on care for people
with Parkinson’s disease in North Adelaide?• Is the service the people in our population with atrial fibrillation
below the minimal acceptable standard of high quality, ie in the top quartile in the middle of the range (a-b)
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Hierarchy Network
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OBJECTIVES FOR AN ASTHMA SYSTEM
•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
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•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
LOW VALUE (BUREAUCRACY BASED CARE)
HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)
Deliver Care through Population-based Systems
Develop clinical focus on populations
Personalise care & decision making
How to achieve high value through Population and Personalised care
Evidence,
Derived from
the study of
groups of
patients
The values this patient
places on the problem that
matter most to them, and on
benefits & harms of the options
The clinical and social condition of this
patient; other diagnoses, risk factors
and their genetic profile
Choice Decision
Personalised and Patient Centred Care
LOW VALUE (BUREAUCRACY BASED CARE)
HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)
Deliver Care through Population-based Systems
Develop clinical focus on populations
Personalise care & decision making
Change the Culture to a collaborative culture
How to achieve high value through Population and Personalised care
“The culture of a group can now be defined as a pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.”Source: Schein, E.H. (2004) Organizational Culture and Leadership. John Wiley & Sons Inc. (p.17).
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“Leadership …and a company’s culture are inextricably interwined.”Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System
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• Observe the artifacts
• Read the documents
• Speak to informants
ASSESSING THE CULTURE
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PrimarySecondaryAcuteCommunityManagerOutpatientHubandSpoke
Introduce new language
A 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(delivered as a service the configuration of which may vary from one population to another )
A NETWORK is a set of individuals and organisations that deliver the system’s objectives(a team is a set of individuals or departments within one organisation)
A PATHWAY is the route patients usually follow through the network
A PROGRAMME is a set of systems with ha common knowledge base and a common budget
Ban old language
Introduce new language eg MUDA
LOW VALUE (BUREAUCRACY BASED CARE)
HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)
Deliver Care through Population-based Systems
Develop clinical focus on populations
Personalise care & decision making
Change the Culture to a collaborative culture
How to achieve high value through Population and Personalised care
DIGITAL KNOWLEDGE
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Map of Medicine - COPD
Work like an ant colony; Neither markets
nor bureaucracies can solve the challenges
of complexity
