Professor Sir Muir Gray qualified in medicine in Glasgow and has worked for many years in public health for the UK National Health Service, most recently as director of the UK National Knowledge Service and chief knowledge officer. He was the founding director of the UK National Screening Programmes, and also of the National Library for Health. He was awarded the CBE, and later a knighthood, for services to the NHS.
Professor Jonathon Gray is the director of Ko Awatea. He has more than thirty years’ experience in the field of health and is an expert in healthcare improvement and innovative service development. After working in different countries, in both academic and frontline leadership positions, he is now focused on building world class improvement capacity to drive local, national and international change.
Tremendous progress has been made over the last forty years due to the second healthcare revolution, with the first healthcare revolution having been the public health revolution of the nineteenth century. Hip replacement, transplantation, and chemotherapy are examples of the high-tech revolution funded by increased investment and, in the last twenty years, optimised by improvements in prevention, quality, safety and evidence-based decision-making.
However, there are still three outstanding problems which are found in every health service no matter how they are structured and funded. One of these problems is huge and unwarranted variation in access, quality, cost and outcome, and this reveals the other two:
• Underuse, which results in inequity and failure to prevent the diseases that healthcare can prevent and may also aggravate.
• Overuse, which results in patient harm, even when the quality of care is high, and in waste – that is, anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients.
In addition, the services will have to cope with rising need and demand without additional resources. What is needed is a focus on value, which has three aspects. One of these focuses on the individual, with two relating to the population’s health.
• Personalised value, determined by how well the outcome relates to the values of each individual.
• Allocative value, determined by how well the assets are distributed to different sub-groups in the population.
• Technical or utilisation value, determined by how well resources are used for outcomes for all the people in need in
We do need to continue with prevention, evidence-based decision-making, quality improvement and cost reduction. But more of the same is not the answer. The focus now has to be on better value for individuals and populations. To achieve this we need three new additional activities. The first of these is increasing personal value by providing people with full information about the risks and benefits of intervention being offered. The second is increasing value for the population by increasing investment in budgets for populations where there is evidence of underuse and inequity by shifting resource from budgets where there is evidence of overuse or lower-value interventions. The third activity is developing population-based systems that address the needs of all the people in need, with specialist services seeing those who would benefit most, and that increase rates of higher-value interventions funded by reduced spending on lower-value interventions, e.g. shifting resources from treatment to prevention, or from polypharmacy to district nursing.
These additional activities require new skills and concepts. Training is needed to help people answer questions such as:
• What do you understand by the term ‘complexity’?
• What is meant by the term ‘system’ and how does it differ from a network?
• What is meant by population-based healthcare rather than bureaucracy-based care?
• What are the three meanings of the term ‘value’ in 21st century healthcare? Not ‘values’ as in ‘we value diversity’, but the economic meanings.
• What is the relationship between value and efficiency?
Value-based healthcare embraces evidence-based decision-making and quality improvement, but it is a broader concept. It is the future, and the future is already here; it is just not evenly distributed.