This week’s paper of the week is brought to you by Professor Sir Muir Gray, 3V Executive Director.
Bottom line (chosen from the paper)
But there is a concern that ‘value’ as currently practised may mean monetary cost coming first, and may be used to describe the values of a balanced accounting sheet rather than the personal values of an individual patient. Higher-quality care may happen to be less expensive, but cost should not be the sole arbiter. Yet the opportunity cost of doctors having to explain why CCGs are no longer funding prescriptions for ‘self-limiting’ conditions, rather than doing other work, has not been factored, and the fuzzy reality of general practice means that it is hard to police a line between ‘mild migraine’ or ‘mild acne’ whose medication should not be funded versus that which is. …
One driver for individual clinicians to continue to provide treatments that are not good value according to the available evidence is the very human desire to ‘do something’ when asked for help, a cognitive shortcut that could be classified as action bias. Take the example of tonsillectomies presented by Šumilo et al in this issue of the BJGP. They found that the vast majority [88.3%] of children undergoing tonsillectomy in the UK do not have an evidence-based indication and large numbers of patients with an indication kept their tonsils. …
Shared decision making is imperative, and although research shows that use of patient decision aids often result in patients choosing less invasive treatment options, we need more work in this area to find whether shared decision aids can assist in lowering unwarranted variation in interventions. Indeed, we think medical practice can be made better for staff and patients through evidence-based, shared decision making. We also suspect this has the potential to decrease unnecessary interventions, thus leaving more resource for valuable ones. The NHS as a whole must work to support patients and clinicians to be able to find, communicate, and discuss the evidence they need to help make high-value choices before, during, and after the consultation.
Implications for value improvement
The key points from this paper are similar to the message of Martin Marshall’s editorial in the Christmas edition of the BMJ titled Rethinking Medicine:
Increasing numbers of doctors and patients are questioning whether medicine has overstretched itself, whether it is always as effective as proponents claim, and whether there are instances when the side effects and unintended consequences outweigh the benefits.
We need to continue with the processes that have increased effectiveness and value in previous decades namely:
- Prevention, not only the primary prevention of disease but also tertiary prevention of dementia and frailty to reduce need
- Evidence based decision making
- Improving outcome by increasing quality and safety of process
- Increasing productivity by reducing cost
But more of the same, even better, quality, safer care is not the answer and four new activities are required:
- Ensuring that every individual achieves high personal value by providing people with full information about the risks and benefits of the intervention being offered
- Increasing population value by shifting 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
- Creating the culture of stewardship
- Developing population based systems and networks
Finally as we highlight these papers that will become classics, it is worth revisiting David Eddy’s classic of 1993 on ‘Three Battles to Watch in the 1990s’
The three battles are on evidence, cost and physician autonomy
1. Rethinking medicine BMJ 2018; 363 Published 13 December 2018) BMJ 2018;363:k4987
2. Three Battles to Watch in the 1990s David M. Eddy, MD, PhD. JAMA.1993;270(4):520-526. doi:10.1001/jama.1993.03510040124050