Why act?
Helen Hirst
Director of CCG Development, NHS England
Prof Sir Muir Gray
Joint National Lead, NHS Right Care &
Public Health England
Twitter
#CforValue
1 NHS | Presentation to [XXXX Company] | [Type Date]
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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
What do we want to achieve?
High Value Healthcare which
•Allocates resources for optimal value & equity
•Makes optimal value from the use of allocated
resources
•Ensures each individual receives care that addresses
their particular problem and values
More of the same is not the answer ,
not even better quality, safer, greener
cheaper of the same
we need to design, plan and build a
new paradigm
VALUE
Triple Value Programme
Individual &
Personalised
Allocative,
Technical,
resources distributed
to optimise value
resources used
to best effect
Allocative value
Between Programme
Marginal 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 £
Cancer
Respiratory
Gastrointestinal
Between Programme
Marginal Analysis and
Mental
reallocation is a
Health
commissioner
responsibility with public
involvement
Cancer
Respiratory
Gastrointestinal
Within Programme,
Between System
Marginal analysis is
a clinician
responsibility
Cancers
Respiratory
Gastroinstestinal
Asthma
COPD
(Chronic
Obstructive Apnoea
Pulmonary
Disease)
Within Programme
Between System
Marginal analysis
Cataract
Retinopathy
Eyes &
Vision
£2Bn
Respiratory
Cancers
Low
Vision
AMD
Glaucoma
Specialist
Commissioning
Terra incognita
Mental
Health
Cancer
Respiratory
Gastrointestinal
Many people
have more than
one problem ;
GP’s are skilled in
managing
complexity
Mental
Health
Cancers
Respiratory
Gastrointestinal
Triple Value Programme
Individual &
Personalised
Allocative,
Technical,
resources distributed
to optimise value
resources used
to best effect
Technical Value = Outcomes / Costs
Outcome= Benefit (EBM +Quality) –
Harm (Safety )
Costs (Money + time + Carbon)
Within System
Marginal Analysis is a
clinician responsibility
with patient
involvement
Cancers
Asthma
COPD
(Chronic
Obstructive Apnoea
Pulmonary
Disease)
Respiratory
Gastroinstestinal
Triple Drug
Smoking
Therapy
cessation
O2
Rehabilitation
The law of diminishing returns
Benefits
Investment of resources
Harmful effects increase in direct proportion
to the resources invested
Harmful or
Side effects
Of care
Investment of resources
After a certain level of investment the health
gain may start to decline;
the point of optimality
Benefits
Benefits - harm
Harms
Investment of resources
Triple Value Programme
Individual &
Personalised
Allocative,
Technical,
resources distributed
to optimise value
resources used
to best effect
The values this patient
places on benefits &
harms of the options
Evidence,
Derived from
the study of
groups of
patients
Choice
The clinical and social condition of this
patient; other diagnoses, risk factors
and their genetic profile and in
particular their problem, what bothers
them psychologically
Personalised and Stratified Medicine
Decision
As the rate of intervention in the population
increases, the balance of benefit and harm
also changes for the individual patient
Necessary
High value
appropriate
inappropriate
Low value
futile
Negative Value
How do we achieve High Value Healthcare?
•Deliver care through population based sustainable
systems focused on
•symptoms like breathlessness or,
•conditions such as epilepsy or
•people with a common characteristic such as being
elderly with frailty
•Be transparent with annual reports from systems to the
patients served
•Have a collaborative culture
•Have all key people trained in new terms, concepts and
skills
•Engage patients as, at the least, equals
The Healthcare Archipelago
GENERAL
PRACTICE
MENTAL
HEALTH
COMMUNITY
SERVICES
HOSPITAL
SERVICES
The Commissioning Archipelago
GP/
Pharmacists/
optometrists
Public
Health
152
Local
Authorities
211 CCG’s
Specialist
commissioning
SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST
SUPER
SPECIALIST
IF YOU ASKED EVERY HEALTHCARE PROFESSIONAL
What is Equity, and how does it differ from
Equality
How does Quality of care differ from Value?
What is meant by optimal end of life care?
How consistent would be the response
We need mandatory training
BetterValueHealthcare
Map of Medicine - COPD
Work like an ant colony; Neither markets
nor bureaucracies can solve the challenges
of complexity
BetterValueHealthcare
Right Care for Populations
The NHS Right Care website offers resources
to support CCGs in adopting this approach:
• online videos and ‘how to’ guides
• casebooks with learning from previous
pilots
• tried and tested process templates to
support taking the approach forward
• advice on how to produce “deep dive”
packs locally to support later phases,
within the CCG or working with local
intelligence services
• access to a practitioner network
Find the full series at:
www.rightcare.nhs.uk/resourcecentre
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