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Muir Gray at the First National Conference on Health Care Quality Registers

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“the future is already ...

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Muir Gray at the First National Conference on Health Care Quality Registers

  1. 1. The future is not like the North Pole, a destination awaiting our arrival…..
  2. 2. It is much more like a bridge between Sweden and Finland, something we imagine, design, plan and build,
  3. 3. www.3VH.org © 2018 Oxford Centre for Triple Value Healthcare Ltd All Rights Reserved @3VHealthcare “the future is already here, it is just not evenly distributed” william gibson the Neuromancer 1984
  4. 4. www.3VH.org THE PRESENT Period of high dependency on other people HEALTHSPAN LIFESPAN
  5. 5. www.3VH.org Wealthiest Quintile Period of high dependency on other people Most deprived Quintile HEALTHSPAN LIFESPAN
  6. 6. www.3VH.org 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
  7. 7. www.3VH.org 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
  8. 8. www.3VH.org 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
  9. 9. www.3VH.org 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
  10. 10. www.3VH.org The first problem is underuse: prevention of complications Range: 30.4%-76.4% Degree of variation: 2.5-fold
  11. 11. www.3VH.org 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
  12. 12. www.3VH.org 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
  13. 13. www.3VH.org Benefit Resources Underuse EffectSize Overuse Harm
  14. 14. www.3VH.org Benefit Resources Underuse Benefit - Harm EffectSize Point of Optimality Overuse Harm
  15. 15. www.3VH.org 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
  16. 16. www.3VH.org 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
  17. 17. www.3VH.org Example of overuse Range: 4.5-18.0% Degree of variation: 4.0-fold difference England median: 11% DoH goal by 2018: <10%
  18. 18. www.3VH.org 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
  19. 19. www.3VH.org 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.
  20. 20. www.3VH.org Effectiveness Evidence- based Cost- effectiveness Quality and Safety Value Conceptualising value: a 21st century paradigm
  21. 21. www.3VH.org 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
  22. 22. www.3VH.org Productivity Outputs/Costs e.g. average length of stay for elective knee replacement
  23. 23. www.3VH.org v Productivity Efficiency Outcomes/costs e.g. Quality Adjusted Life Year for a given intervention % of people having had a knee replacement who report a good outcome/ DRG cost NB this is the US definition of value
  24. 24. v Productivity Outputs/ Resources Efficiency Outcomes/ Resources Technical Value Are the right patients being seen or is there either 1. harm from over diagnosis or 2. inequity from underuse Triple Resources • Financial • Environmental (carbon) • Time, not only clinician time but also time of patients and carers
  25. 25. www.3VH.org • 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
  26. 26. www.3VH.org 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
  27. 27. www.3VH.org 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
  28. 28. www.3VH.org 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
  29. 29. www.3VH.org • 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
  30. 30. www.3VH.org Mental Health £145M Cardio £100M Respiratory £78M Gastro- Intestinal £68MEyes and vision £30M Annual Spend Per Million
  31. 31. www.3VH.org 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
  32. 32. www.3VH.org Cancers Respiratory Gastro- instestinal Apnoea COPD (Chronic Obstructive Pulmonary Disease) Asthma
  33. 33. www.3VH.org 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.
  34. 34. www.3VH.org • 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
  35. 35. www.3VH.org Structure Systems & Public Professionals Networks Culture Patients INFLUENCE CREATE
  36. 36. www.3VH.org The Healthcare Archipelago GENERAL MENTAL PRACTICE HEALTH PRIVATE HOSPITAL PHYSIOTHERAPY OSTEOPATHY SERVICES CHIROPRACTIC
  37. 37. www.3VH.org 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 ….. …..
  38. 38. www.3VH.org 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
  39. 39. www.3VH.org 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?
  40. 40. www.3VH.org 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?
  41. 41. www.3VH.org SELF CARE INFORMAL CARE GENERALIST SPECIALIST
  42. 42. www.3VH.org SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST
  43. 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. 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
  45. 45. www.3VH.org BetterValueHealthcare Hierarchy Network
  46. 46. www.3VH.org BetterValueHealthcare Hierarchy Network
  47. 47. www.3VH.org Within systems are different interventions Respiratory Smoking cessation Imaging Physiotherapy Triple drug therapy
  48. 48. www.3VH.org All people with the condition People receiving The service People who would benefit most from the service
  49. 49. www.3VH.org 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
  50. 50. www.3VH.org • 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
  51. 51. www.3VH.org 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
  52. 52. www.3VH.org 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

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