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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 HOSPITAL 
SERVICES SERVICES
JURISDICTIONS INSTITUTIONS 
PROFESSIONS 
REGULATORS AND INSPECTORS
• 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) 
BetterValueHealthcare
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
Allocative efficiency 
Cancer 
Respiratory 
Gastro-intestinal 
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 £ 
from one budget to 
another
Cancer 
Respiratory 
Gastro-intestinal 
Between Programme 
Marginal Analysis and 
reallocation is a 
commissioner 
responsibility with public 
involvement 
Mental 
Health
Cancers 
Respiratory 
Gastro-intestinal 
Mental 
Health 
Many people 
have more than 
one problem ; 
GP’s are skilled in 
managing 
complexity
Medically 
Unexplained 
Physical 
Symptoms 
Homeless 
people 
Children 
Older 
People 
With four 
or more 
diagnoses
Cancers 
Gastro-instestinal 
Respiratory 
Obesity 
Liver 
Gastro 
Intestinal 
Within Programme, 
Between System 
Marginal analysis is 
a clinician 
responsibility
Cancers 
MSK 
RA 
OA/Joints Porosis 
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 
Higher 
Value 
High 
Value 
Lower 
Value 
Lower Value 
THE INSTITUTIONAL 
APPROACH
After a certain level of 
investment, health gain 
may start to decline 
Benefits 
Harms 
Investment of resources 
Benefits - harm 
Point of optimality 
1. Reduce lower or negative 
value activities
Cancers 
Respiratory 
Gastro-instestinal 
Apnoea 
Asthma 
COPD 
(Chronic 
Obstructive 
Pulmonary 
Disease) 
Triple Drug 
Therapy 
O2 
Smoking 
cessation 
Rehabilitation 
Within System 
Marginal Analysis is a 
clinician responsibility 
with patient 
involvement
Cancers 
MSK 
RA 
OA/Joints Porosis 
Replacement 
MRI 
Arthro 
/washout 
Respiratory
Hellish Decisions in Healthcare 
All people with the condition 
People receiving the 
specialist service 
People who would 
benefit most from 
the specialist service 
3. See the right 
patients
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 
Choice Decision 
The clinical and social condition of this 
patient; other diagnoses, risk factors 
and their genetic profile 
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 
BENEFIT 
HARM 
Necessary appropriate inappropriate futile 
High value Low value Negative Value
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 
DIGITAL KNOWLEDGE 
Change the 
Culture to a 
collaborative 
culture
The Healthcare Archipelago 
GENERAL MENTAL 
PRACTICE HEALTH 
COMMUNITY HOSPITAL 
SERVICES SERVICES
Chaos…..….Complexity……...Order 
Person aged 87, 5 diagnoses 
8 prescriptions, cared for by 
Daughter with alcoholic husband 
Man aged 67 with 
Dukes A colorectal ca. 
Man aged 23, Potts# 
Football 
woman aged 45 
invited for cervical 
screening 
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 up 
as a system
Hierarchy Network 
BetterValueHealthcare
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 provided 
evidence 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 development 
Quality of patient information 
Professional 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
• 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) 
BetterValueHealthcare
Hierarchy Network 
BetterValueHealthcare
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 
BetterValueHealthcare
•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 
BetterValueHealthcare
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 
Choice Decision 
The clinical and social condition of this 
patient; other diagnoses, risk factors 
and their genetic profile 
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).
“Leadership …and a company’s culture 
are inextricably interwined.” 
Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System 
BetterValueHealthcare
ASSESSING THE CULTURE 
• Observe the artifacts 
• Read the documents 
• Speak to informants 
BetterValueHealthcare
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 
BetterValueHealthcare 
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 
DIGITAL KNOWLEDGE 
Change the 
Culture to a 
collaborative 
culture 
How to achieve high value through Population and Personalised care
Map of Medicine - COPD 
Work like an ant colony; Neither markets 
nor bureaucracies can solve the challenges 
of complexity 
BetterValueHealthcare

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value based healthcare

  • 1. - 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
  • 2. 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)
  • 3.
  • 4.
  • 5. The Healthcare Archipelago GENERAL MENTAL PRACTICE HEALTH COMMUNITY HOSPITAL SERVICES SERVICES
  • 6. JURISDICTIONS INSTITUTIONS PROFESSIONS REGULATORS AND INSPECTORS
  • 7. • 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) BetterValueHealthcare
  • 8. 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
  • 10. Allocative efficiency Cancer Respiratory Gastro-intestinal 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 £ from one budget to another
  • 11. Cancer Respiratory Gastro-intestinal Between Programme Marginal Analysis and reallocation is a commissioner responsibility with public involvement Mental Health
  • 12. Cancers Respiratory Gastro-intestinal Mental Health Many people have more than one problem ; GP’s are skilled in managing complexity
  • 13. Medically Unexplained Physical Symptoms Homeless people Children Older People With four or more diagnoses
  • 14. Cancers Gastro-instestinal Respiratory Obesity Liver Gastro Intestinal Within Programme, Between System Marginal analysis is a clinician responsibility
  • 15. Cancers MSK RA OA/Joints Porosis Respiratory
  • 17. Technical Value (Efficiency) = Outcomes / Costs Outcome= Benefit (EBM +Quality) – Harm (Safety ) Costs (Money + time + Carbon)
  • 18. Added value from doing things right (quality improvement) Higher Value Higher Value High Value Lower Value Lower Value THE INSTITUTIONAL APPROACH
  • 19. After a certain level of investment, health gain may start to decline Benefits Harms Investment of resources Benefits - harm Point of optimality 1. Reduce lower or negative value activities
  • 20. Cancers Respiratory Gastro-instestinal Apnoea Asthma COPD (Chronic Obstructive Pulmonary Disease) Triple Drug Therapy O2 Smoking cessation Rehabilitation Within System Marginal Analysis is a clinician responsibility with patient involvement
  • 21. Cancers MSK RA OA/Joints Porosis Replacement MRI Arthro /washout Respiratory
  • 22. Hellish Decisions in Healthcare All people with the condition People receiving the specialist service People who would benefit most from the specialist service 3. See the right patients
  • 23. High Value Innovation + Disinvestment from Lower Value Interventions
  • 25. 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 Choice Decision The clinical and social condition of this patient; other diagnoses, risk factors and their genetic profile Personalised and Patient Centred Care
  • 26. “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).
  • 27. After a certain level of investment the health gain may start to decline; the point of optimality Benefits Investment of resources Harms Benefits - harm
  • 28. As the rate of intervention in the population increases, the balance of benefit and harm also changes for the individual patient BENEFIT HARM Necessary appropriate inappropriate futile High value Low value Negative Value
  • 29. 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 DIGITAL KNOWLEDGE Change the Culture to a collaborative culture
  • 30. The Healthcare Archipelago GENERAL MENTAL PRACTICE HEALTH COMMUNITY HOSPITAL SERVICES SERVICES
  • 31. Chaos…..….Complexity……...Order Person aged 87, 5 diagnoses 8 prescriptions, cared for by Daughter with alcoholic husband Man aged 67 with Dukes A colorectal ca. Man aged 23, Potts# Football woman aged 45 invited for cervical screening 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
  • 32. 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).
  • 33. SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST
  • 34. This is an example of a national service set up as a system
  • 36.
  • 37. 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
  • 38. Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and provided evidence based, patient centred care, and to improve effectiveness, productivity and safety
  • 39. 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
  • 40. 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 development Quality of patient information Professional 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
  • 41.
  • 42.
  • 43. • 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) BetterValueHealthcare
  • 45. 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 BetterValueHealthcare
  • 46. •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 BetterValueHealthcare
  • 47. 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
  • 48. 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 Choice Decision The clinical and social condition of this patient; other diagnoses, risk factors and their genetic profile Personalised and Patient Centred Care
  • 49.
  • 50. 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
  • 51. “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).
  • 52. “Leadership …and a company’s culture are inextricably interwined.” Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System BetterValueHealthcare
  • 53. ASSESSING THE CULTURE • Observe the artifacts • Read the documents • Speak to informants BetterValueHealthcare
  • 54. 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 BetterValueHealthcare Ban old language
  • 56. 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 DIGITAL KNOWLEDGE Change the Culture to a collaborative culture How to achieve high value through Population and Personalised care
  • 57. Map of Medicine - COPD Work like an ant colony; Neither markets nor bureaucracies can solve the challenges of complexity BetterValueHealthcare