Abstract
After 70 years of a National Health Service, we still cannot answer simple questions such as:
Is the service for people with seizures and epilepsy in Manchester better than the service in Liverpool? Who is responsible for the headache service for people in Southampton? How many liver disease services are there in England and how many should there be? Which service for frail elderly people in London provides the best value? Who is responsible for the quality, outcome and value of the service for people with bipolar disorder in Suffolk?
The answer to these questions, all of them, is ‘don’t know’. People working in England should not be too concerned, because these questions cannot be answered in any country and can be reframed as set out below.
Is the service for people with seizures and epilepsy in London better than the service in Paris? Who is responsible for the headache service for people in Milano or Sydney? How many liver disease services are there in Ireland and how many should there be? Which service for frail elderly people in Ontario provides the best value? Who is responsible for the quality outcome and value of the service for people with bipolar disorder in West Wales and is it better than the service for people in the West of Scotland?
We have some information about some cancers which would allow us to address such questions; but cancers, important though they are, are only one of about 30 major health challenges, and hence, from a population perspective, we know virtually nothing about what is happening in any country’s population, although we do know what is happening in some hospitals that have joined a benchmarking project.
What is needed is to complement the focus on the quality of institutional provision with a focus on value for the population to shift resources from lower value use to higher value activity and value has three aspects:
Allocative, determined by how well the assets are distributed to different subgroups in the population; Technical, determined by how well resources are used for outcomes for all the people in need in the population, this is much more than efficiency which is determined by the outcomes and costs of the patients seen but ignores overuse and underuse; Personalised value, determined by how well the outcome relates to the values of each individual.
What is needed to increase value is to continue with the processes that have increased effectiveness and value in previous decades, namely strong general management and leadership skills combined with four specific or contextual management activities, contextual in that they are relevant only to health services:
Preventing disease, disability, dementia and frailty to reduce need; Improving outcome by providing cost-effective interventions determined by research and evidence-based decision-making; Improving outcome by increasing quality and safety of process; Increasing productivity by reducing cost.
But more of the same, even better quality care is not the answer. The focus has to be on value, on better value for individuals and populations. To achieve this, we need five new activities:
Ensuring that every individual achieves high personal value; Shifting resource from programmes, where there is evidence of overuse or lower value to programmes where there is underuse of high value interventions; Ensuring that the right people reach the service; Implementation of high value innovation by reduced spending on lower value care in that system; Increased rates of higher value intervention within a single system funded by reduced spending on lower value care.
This requires a new approach defined as population healthcare, namely an approach to health and social care focused 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. To achieve this requires no structural reorganisation, although there are some structural disincentives that need to be removed but a new paradigm. The future will not be like the past and needs a new design.
Designing the future
[Design] as a word is common enough, but it is full of incongruities, has innumerable manifestations, and lacks boundaries that give clarity and definition but, stripped to its essence, can be defined as the human capacity to shape and make our environment in ways without precedent in nature, to serve our needs and give meaning to our lives. (John Heskett, 2005)
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The wake of the Titanic was perfect until it was too late to do anything about it; the dials of the Titanic were all showing perfect performance, the pressure was right and the electricity was flowing perfectly until it was too late to do anything about it. One of the reasons that the Titanic hit the iceberg was because the lookouts did not have binoculars. It is important to look ahead and, even more important, not just look at but design the future. The future is not a destination like the Isle of Wight or Tasmania, awaiting our destination. The future is much more like the Great Western Railway or the Forth Bridge, something that we have to design, plan and build. The future is not so difficult to design as some people fear and it does not require visions because, in the words of William Gibson, the future is here, it is just not evenly distributed.
Learning from the past
It is, however, helpful to think about the past because it can also give pointers to the future and we have had two healthcare revolutions which have been of terrific importance.
The first revolution was the public health revolution, and it was based, like the first Industrial Revolution, on empiricism, on simply observing the relationship between events and drawing logical conclusions. John Snow did not know that bacteria were the source of infectious diseases, because they had not even been discovered. He simply observed that cases of cholera were associated with the water supply and not with the air, as another theory held. The first healthcare revolution, like the first industrial revolution, was based on empiricism. James Watt had no idea about the physics of steam; he simply looked at the kettle lid bumping up and down in his mother’s kitchen and worked out what can be done with it.
Innovations of the second healthcare revolution.
It is important to emphasise that it is every society that faces these problems – tax-based systems and insurance-based systems, private systems and public systems, systems with co-payments and systems without co-payments: all these different structures face the same problems. It is for this reason that we can draw the conclusion that structural change in the structure of a health service or in the way in which it is financed will not solve the problems that every health service faces.
Three types of organisation are involved in healthcare:
Jurisdictions, politically defined organisations that allocate resources – for example, provinces, states and, in England, local authorities and clinical commissioning groups; Institutions that deliver sets of services – hospitals, mental health trusts and primary care teams, for example; Professions, their demarcation lines little changed since the 19th century.
What is clear is that, although each of these different types of organisation has a very important part to play, the task of delivering health services is too complex for them to achieve, no matter how detailed the contracts that seek to govern their relationships.
A new paradigm is needed for the new context.
Defining the context
The Network Society is the term made popular by the academic Manuel Castells
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to describe a new world in which relationships are more important than entities, a world in which the Internet plays a huge part not only technically but also culturally. In designing the future of healthcare, therefore, it is essential to think about the society in which healthcare will be provided. In his management classic The Innovator’s Dilemma,
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Clayton Christensen pointed out how ‘new technology can cause great companies to fail’. By this, he meant that companies like Kodak, which were very successful, became complacent and hung onto the old way of working to a point at which they could not recover. Clayton Christensen, with two colleagues who were medically trained, also wrote a book called The Innovator’s Prescription,
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suggesting completely new ways of running a health service powered by the Internet and, in their view, the human genome, and in his influential trilogy on the Network Society, Manuel Castells talks about three industrial revolutions and says that the third industrial revolution has already started. This revolution, unlike the second is a revolution driven not by the leaders of industry or by politicians but by three interrelated forces – citizens, knowledge and the smartphone. The same forces are driving the third healthcare revolution (Figure 1).
The Drivers of the Third Healthcare Revolution
Driven by these factors, a new paradigm is emerging.
Shifting paradigms
The term ‘paradigm shift’ has been widely used and misused since it was first created by Thomas Kuhn in his highly respected book called The Structure of Scientific Revolutions. 4 The paradigm is the dominant way of thinking, a way of thinking that analyses problems in a certain way and defines solutions in a certain way; it is defined by Rupert Smith as: Universally recognized scientific achievements that for a time provide model problems and solutions to a community of practitioners. 5
In the second half of the 20th century, the principal paradigm to emerge was that healthcare was a right and not a privilege, expressed in Great Britain by the creation of the National Health Service. This paradigm was also accepted in every developed country, with the exception of the United States. In Great Britain, therefore, the key paradigm from 1948 was that healthcare was free.
The effectiveness and evidence-based paradigm
In 1972, Archie Cochrane published a book called Effectiveness and Efficiency 6 and this changed the paradigm. No longer was it sufficient to provide treatment that was free; the treatment had to be free and effective. Cochrane’s paradigm shift led of course to the Cochrane Collaboration and, by promoting epidemiology as a key discipline for clinicians, to clinical epidemiology and evidence-based medicine. The first book that was published by McMaster University Medical School was called Clinical Epidemiology, 7 subtitled a Basic Science for Clinical Medicine. They then followed this up later by developing the paradigm of Evidence Based Medicine. 8
The Cost-effectiveness paradigm
In the 1990s, even though the economies of many developed countries were under pressure, investment in healthcare was still growing. However, it came to be realised that effectiveness by itself was insufficient and cost-effectiveness was required, a concept promoted particularly by NICE, its original name being the National Institute for Clinical Excellence. In the decade of the 1990s, therefore, the key issue was whether or not interventions were effective and cost-effective, but around the time of the millennium three landmark reports were produced that led to the next paradigm shift.
The quality and safety paradigm
The Institute of Medicine in Washington, DC produced two reports in the year 2000. One was called Crossing the Quality Chasm, 9 highlighting the gap between how good healthcare could be and how good its quality actually was in most institutions in most countries. Its second report was about errors and patient safety and was called To Err Is Human. 10 This was complemented by a report published the same year by Sir Liam Donaldson, then Chief Medical Officer of the Department of Health in London, who called his report An Organisation With A Memory, 11 emphasising the need to learn from mistakes and reduce the probability that they would recur in future. This led to the quality and safety paradigm.
However, it is important to emphasise that a paradigm does not necessarily destroy the preceding paradigms; it can embrace and enfold them. The quality and safety paradigm was based on the assumption that only effective and cost-effective interventions were being offered and emphasised that they should be delivered to high levels of quality and safety, and this seemed the last word in healthcare. However, towards the end of the first decade of 21st century, an event took place that brought in the next paradigm shift – the value paradigm.
The triple value era
Of these five changes, perhaps the most significant is the focus on value.
The term is quite a difficult term because it has many different meanings. Values, when the word is used in the plural, refer to principles – for example, ‘we value the equality and diversity’. When the word ‘value’ is used in the singular, it has an economic meaning and this translates well in every language, even though the assessment is subjective and not objective.
Value is, of course, a complex subject and most of the debate hitherto has been about what economists call ‘technical efficiency’, namely outcomes related to cost. However, this is only one of three types of value in the triple value paradigm and the three types are shown below:
Allocative value, determined by how the assets are distributed to different subgroups 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.
There are three levels of allocative decision-making once the decision on how much to top-slice for research and education and the decision on geographical allocation have been made. These three levels of allocative decision-making are:
Between-programmes – for example, between cancer and mental health or vice versa, although judging the value derived from allocation to different programmes is complicated in the NHS in England because the resources for specialised services are top-sliced before the geographical allocation is made; Within-programme/between systems – for example, between asthma, chronic obstructive pulmonary disease (COPD), sleep apnoea and breathlessness within the respiratory programme budget; Within-system – for example, within the resources available for COPD.
The technical value, or efficiency, of an enterprise is measured by relating its outcomes and results to the resources used, but there are many different perspectives on value. To a manufacturer, value is measured by the return on investment, to a hospital manager, value can be related to the fee they receive for the service and how it relates to their costs, but the two perspectives on value that will dominate the debate in healthcare are the population perspective and the individual patient perspective. For this reason, we can conclude that the value paradigm will lead to the dominant approach to healthcare being, on the one hand, focused on the population and, on the other, on the individual patient or person. Michael Porter’s definition of the word value illustrates how this new paradigm incorporates the previous one. ‘Since value is defined as outcomes relative to costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false “savings” and potentially limiting effective care’. 12
It is equally important to incorporate quality and safety in the value paradigm. Improvements in quality and safety increase the probability of good outcomes and decrease the probability of bad outcomes, respectively. So such initiatives increase value but only up to a point. There comes a point at which further investment in quality and safety improvement will not represent high value.
