All health services committed to universal healthcare face what appears to be an apparently inexorable growing pressure from:

  • increasing need;
  • rising demand;
  • limited resources, not only financial but, as the pandemic highlighted, other finite resources notably staff time, beds, operating theatres and equipment;
  • increasing restrictions on carbon.

The challenge will put pressure on their commitment to provide universal healthcare, but how can this gap between need and demand, and resources 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 outcome by providing only cost-effective, evidence-based interventions.
  • Improving outcome 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 these activities , focused on patients and not on populations have resulted in large degrees of unwarranted variation in spending and activity and this in turn revelas two other problems of great significance

  • Overuse and waste of reseources
  • Underuse and inequity

Furthermore, after 70 years of a purportedly National Health Service, we still cannot answer questions like:

  1. Who is responsible for the service for people with multimorbidity in population A?
  2. What is the variation in spend on COPD and how does this relate to need and outcome?
  3. Who is responsible for the service for women with pelvic pain in Population B and does it provide better value than the service in Population B or Population C ?
  4. How many services are there for people with Musculoskeletal Disease in this country and and which gives best value?
  5. Is the variation in outcome and spend for people with atrial fibrillation in increasing or decreasing and is it better in Population X or Population Y

The new paradigm

We need a new paradigm that 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 and has four dimensions:

Personal value – appropriate care to achieve the goal that matters most to the person related to the problem that was bothering the person most

Technical value achievement of best possible outcomes with available resources; it is important to emphasise that this means using the resources for all the people in need in the population not just those who reach the service and become patients, for example focusing on all the people in with hip pain, not just those people who have had a hip replacement. This means that technical value also includes measurement and minimisation of inequity

Allocative value – equitable resource distribution across all populations and within each population across all patient groups

Social value – contribution of healthcare to social participation and connectedness

The same principles were adopted by the G20 Health Ministers and the G20 is setting up a Global Hub to support all its members develop value-based healthcare.

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