All health services committed to universal healthcare were hoping for a reduction in pressure after the COVID-19 pandemic. However, even if the pressure of COVID-19 has decreased, the decade ahead appears to be one of apparently inexorable growing pressure from:
- increasing need and demand, including huge backlogs;
- limited resources, not only financial but, as the pandemic highlighted, other finite resources such as staff time, beds, operating theatres and equipment. There will also be increasing emphasis to reduce that other resource – carbon.
The challenge will put pressure on the commitment to provide universal healthcare, but how can this gap between need and demand on the one hand and resources on the other be closed?
Great progress has been made in healthcare over the last 40 years, most of which has been achieved through technological advances in treatments, complemented by a succession of paradigms focusing on:
- Preventing disease, disability, dementia and frailty to reduce need.
- Improving outcomes by providing only cost-effective, evidence-based interventions.
- Improving outcomes by increasing quality and safety of process.
- Increasing productivity by reducing cost.
These all continue to be necessary but more of the same, even if it is better quality and safer care, is not sustainable and three huge problems have remained largely untouched, although they were clearly described by Jack Wennberg and Avedis Donabedian in the 1980s:
- Unwarranted variation in spend, activity and outcome in different populations, which revealed the two other problems
- Overuse of healthcare with an unfavourable balance of benefit to harm and waste of resources
- Underuse of high value healthcare often compounded by inequity
For this reason, a new paradigm is needed.
The new paradigm
The new paradigm focuses on value with a culture of stewardship. But what does value mean?
In the USA, the meaning of the term ‘value’ is conceived as the relationship between outcomes for the patient treated and costs but in countries committed to universal health coverage. This relationship would be termed ‘efficiency’ and in health systems committed to universal coverage, value is a much broader concept than efficiency. The European Union emphasised the need to understand that the commitment to universal healthcare is an expression of the principle of solidarity, a core principle of the European Union. Their definition of value-based healthcare is that it is as a:
“Comprehensive concept built on four value-pillars:
- appropriate care to achieve patients’ personal goals (personal value),
- equitable resource distribution across all segments of the population (allocative value)
- achievement of best possible outcomes with available resources (technical value),
- contribution of healthcare to social participation and connectedness (societal value).”
Every health service needs to deliver higher value and reduce waste where waste is not only unnecessary spend and low productivity but also
- The use of resources in interventions that do not achieve outcomes that matter to patients
- The use of resources that would produce more value if used
for another purpose for that subgroup of the population or
another subgroup of the population.
To develop the new paradigm of value-based healthcare, a new leadership and management agenda has evolved with five inter-related themes:
- Define population sub-groups with a common need and allocate resources optimally
- Design the system for each population sub-group
- Ensure each individual makes decisions to optimise personal value
- Deliver value for the population and all the individuals in need equitably through networks
- Create the culture of stewardship, with a governance process that promotes collective responsibility