This was the topic of discussion at a recent HSMC and Healthcare Financial Management (HFMA) seminar attracting senior clinicians and managers from across the West Midlands region. Participants heard from Professor Sir Muir Gray, Director of Better Value Healthcare, who laid down the challenge about the need to reorientate our health system and practice towards value for patients, and the population.
This was followed by a presentation from practising GP and advisor to NICE (the National Institute for Health and Care Excellence), Dr Tessa Lewis, who shared experience from Wales of implementing the Prudent Healthcare programme which aims to get greater value from healthcare systems for patients.
Whatever the nomenclature for work that seeks to optimise value in healthcare, the attention being given to this agenda in the UK could not be timelier. The context for this was set out at the seminar by David Melbourne, Acting Chief Executive of Birmingham Children’s Hospital and Chair of HFMA’s Research and Development Committee in the West Midlands. In common with all NHS provider chief executives in England, he had just received notification of the savings target his organisation is expected to make in the financial year 2016-2017. He noted that the scale of the challenge was greater than anything presented by cost improvement programmes in recent years, and there was a pressing need to win hearts and minds about fundamentally different ways of organising and delivering health care.
Muir Gray set out the key problems inherent in seeking to optimise healthcare value. These included: tackling unwarranted variation; addressing overuse of lower- or zero-value interventions; and under-use of high-value interventions. Fortunately, given the scale of the financial challenge facing the NHS, there is still plenty to be tackled within each category, whether variation between rates of diagnostic tests across the country, the overuse of arthroscopy in knee degeneration, or the underuse of anti-emetics early on for pregnancy sickness.
Muir Gray also referred to the recent Academy of Medical Royal Colleges report – Protecting resources, promoting value – a doctor’s guide to cutting waste in clinical care, suggesting that the NHS needs to develop a ‘culture of stewardship’ to ensure that we do all we can to preserve the service for generations to come. This will include fundamental organisational and cultural change whereby the NHS is able to encourage clinicians and managers to act as stewards of both resource and value.
This will require action such as employing sharper, more focused planning skills within organisations to ensure that there is the right balance of funding between disease areas and treatment options, and also more fundamental challenge to the idea of professional autonomy as the ultimate arbiter in decision making about care.
Tessa Lewis focused on polypharmacy and reducing inappropriate clinical activity in her presentation and cited the prudent prescribing workshops in Wales as an example of how professional attitudes could be challenged, so that only what is needed is done – a key principle of the Prudent Healthcare programme.
It was agreed by both Muir and Tessa that the patient voice is critical in debates about value and healthcare, in addressing potentially unrealistic patient expectations in cases such as antibiotic prescribing, avoiding heroic interventions in ‘lost cause’ scenarios; and enabling patients to express their preferences for treatment more explicitly. Indeed, research exists that suggests patients tend to choose less invasive care for themselves when in possession of the facts regarding risks and benefits, and that they typically favour quality of care and being pain-free, over unnecessary extending of life, when nearing the end of life.
This is the essence of Choosing Wisely as a movement - one that started as a clinician-led initiative in the USA – to promote conversations between doctors and patients and hence help patients choose care that is: supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary. Inappropriate clinical interventions have been the subject of discussion in the UK context for some time but this agenda has been galvanised by the recent BMJ campaign – ‘Too Much Medicine’.
The Academy of Medical Royal Colleges is currently taking forward the Choosing Wisely programme here in England. Following on from this HSMC and HFMA seminar in Birmingham, the Health Services Management Centre is working with the HFMA to consider ways in which it can support health care organisations in the Midlands and more widely to debate and address the issues raised by this important agenda. We will provide updates in further editions of our newsletter, or you can contact HSMC’s Director of Policy, Hilary Brown for further information - (h.i.brown@bham.ac.uk).