This week’s blog is brought to you by: Dr Tim Wilson

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Full reference and title from the journal:

Can patient centred care plus shared decision making equal lower costs? Gemma Venhuizen, BMJ 2019;367:l5900

Link to paper:


Authors conclusion:

“At Bernhoven, 70% of patients referred for eye care are seen by an optometrist instead of an ophthalmologist. In that way, a consultation costs €40 (£36; $44) instead of €225, and waiting lists have decreased.” (sic)

 3V bottom line:

The result from this paper are encouraging, but language matters. Especially when talking about value-based healthcare. So instead of focusing on lower costs, the author should have talked about “resources being freed up from lower value care for higher value”. The implications were that lower costs would lead to savings which would disappear into an accountant’s spreadsheet, instead of being reinvested for the whole population in need.


3VH – Implications for value:

This is a news article from the BMJ about an interesting hospital in the Netherlands, Benhoven, to implement patient centred care and shared decision making across. The results are impressive showing that a concerted effort over years does appear to reduce volumes of surgery and costs. These results in themselves are important learning.

But language shapes what we think. And there are a number of possible problems with the way the paper is written. The emphasis on costs rather than value implies that lower costs means more savings.

Engaging clinicians and patients in value programmes means we have to use the right language. If they suspect a lower cost approach means savings will be garnered to prop up anonymous incompetence elsewhere, or it is merely an approach for the Insurance company to make more profits (this hospital is in the Netherlands), then they are hardly likely to stay engaged. If, however, they can see resources they’ve freed up from lower value care being reinvested in care elsewhere, ideally for people with the same problem, then the motivation changes completely.

Costs are important in value-based healthcare. But a narrow focus on money ignores the fact that there are many finite resources in healthcare; workforce, leadership time, change capacity and carbon. And if money is released what is it going to be used for?

The other issue in this paper is that this was a hospital. So, the denominator was the patients being treated. We don’t know about people with a problem who didn’t get referred to the hospital, or those with a problem who haven’t even seen their GP. We know that there is inequity in accessing specialist care. So if you are in a universal health system, like the Netherlands, then all we cannot really comment if the population is getting better care as a result of this hospital-based programme- important and impressive though it is.