Task: Value Principles in Healthcare
Time: 1 Hour
Prerequisites: Task 1 - Value in Healthcare Introduction
Learning outcome: 'I understand value principles in healthcare'
Remember to record this activity in your BPV Specialist learning activity log
* denotes optional background reading links
READING: ‘A Culture of Stewardship: The Responsibility of NHS Leaders to Deliver Better Value Healthcare’ by Muir Gray via NHS Confederation and Academy of Medical Royal Colleges
As the stewards of public resources, all health system leaders have a responsibility to deliver better value on behalf of both service users and taxpayers. It’s everyone’s duty to pursue maximum value and make shared decisions about balancing the use of limited financial resources with improving health and wellbeing outcomes.
‘I drive value’ is one of the 4 Strengths*; key attributes the NHS Finance Leadership Council advise finance business partners should develop to play their part in working towards a modern, patient-centred NHS. This framework requires that we assess ideas in line with ‘value principles’.
(Note: whilst BPV is a finance-led programme, value thinking applies to all roles including medical (FMLM leadership standards*) and nursing (Leading Change, Adding Value*), for example).
Healthcare value principles follow the POETIC Vision* (adapted by BPV) when it comes to making decisions about how healthcare resources are used.
Keeping each these principles in mind during day-to-day work is what we mean when we talk about putting ‘value thinking’ into practice:
|Value principle||Value thinking|
|Patient-centred||Are services are designed around patient and population need?|
|Outcomes-driven||Are unifying outcome objectives are clearly defined and agreed?|
|Evidence-based||Are services are designed using best practice to reduce variation?|
|Team-oriented||Does a multi-disciplinary teams share value-based decisions?|
|Integrated||Is there system-wide primary, secondary and social care integration?|
|Cost-aware||Is value-for-money realised?|
Porter’s value equation follows the principle that quality is defined from the perspective of the end user (i.e. service users as patients or the public) as discussed in the previous activity. BPV begins every decision-making process by asking:
What is the health need of the patient?
This person-centric approach ensures that the requirements of our ‘customers’ are met, regardless of our competing agendas as individuals or organisations.
A second use of the ‘P’ is ‘patient pathway’. Healthcare has historically focused on individual interventions with service users. Porter’s Care Delivery Value Chain, for example, encourages thinking about the interactions with the healthcare service from the start to the end of their care journey including prevention, diagnosis, treatment and monitoring. For finance colleagues, this may mean measuring resources or costs across the whole patient pathway or cycle of care for a particular medical condition. For clinical colleagues, this may mean focussing more on prevention and diagnostic activities, for example.
We can also add a third ‘P’ which is ‘patient population’ and thinking about our service users as groups as well as individuals. This is the principle behind NHS RightCare’s (*) work to reduce unwarranted variation between regions.
In thinking about health needs from the patient perspective, we need to ask:
What long-term health outcomes is the service user seeking?
Health outcomes may be defined as “a change in the health status of an individual, group or population which is attributable to a planned intervention or series of interventions” (reference*). Outcomes are a reflection of quality which indicate the longer-term consequences of care interventions for service users, and are often used as a realistic and appropriate reflection of the impact of care activities.
Outcomes are the things that matter to our service users and that allow us to demonstrate that a positive health and wellbeing impact has ultimately been made as a direct result of our choices and actions. Outcomes represent the difference between what action has been taken and what change has been received by the beneficiary.
BPV uses three groups of outcome measures to reflect quality:
Clinicians and finance colleagues hold a join role in measuring, quantifying, monitoring and demonstrating outcomes when making decisions about how healthcare resources are used. This brings us to the next value principle:
In clinical terms, Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information (reference*).
The same principle applies to making operational and strategic decisions about how healthcare resources are used. We must ask:
What is the evidence that this action will add value?
Health and social care systems collect a great deal of data, which can be explored and used as evidence for making decisions about how services are provided to populations. 'The Big-Data Revolution in US Health Care: Accelerating Value and Innovation’* by Basel Kayyali, David Knott, and Steve Van Kuiken via McKinsey & Company explores this idea further.
Using good evidence to make decisions means good governance, a clear audit trail, and incorporates a consideration of risk.
BPV uses logic modelling and an evidence log to demonstrate that a good practice has been used.
In clinical terms, ‘Shared Decision Making’ (SDM) usually refers to a process in which patients, when they reach a decision crossroads in their health care, can review all the treatment options available to them and participate actively with their healthcare professional in making that decision (reference*).
We also need to use shared decision making within teams, to make best use of contributions from all of our areas of expertise. We must ask:
Have the right stakeholders had input into this decision?
Using BPV, we suggest that ‘decision teams’ come together to make decision about service delivery. This means including patients and the public are the experts on the care they wish to receive. Finance, clinical and other colleagues must also provide their expertise to the decision.
Bain’s RAPID tool, for example, can help clarify the roles and responses throughout a decision-making process, to ensure that expert input generates good practice whilst accountability for the decision is maintained.
When considering the first value principle, we can see that the full patient pathway or cycle of care means that an individual will come into contact with many different organisations throughout their medical condition.
For example, public health organisations (regionally and nationally) are engaged with prevention and monitoring; primary care providers may offer a diagnosis and management of a condition; ambulatory and acute providers offer medical intervention services; community service providers will deliver follow-up care and continued monitoring and management.
If we take a patient-centred approach to making decisions about how services are offered, then our decision-making processes must involve each of these players. We must ask
Who else should be involved in making this decision?
'Shared decision-making' from a strategic and organisational perspective means using good business processes and taking a whole-system approach to health and wellbeing.
The value equation rewritten for healthcare (outcomes / resources) seeks to express the competing needs of the patient as the beneficiary and receiver of care versus the taxpayer as sponsor and funder of services. As decision-makers, we are simply the middle custodians of resources on behalf of our service users. Every decision we make must ask:
Is this activity getting the most out of what we're putting in?
A mutual understanding of the tensions between outcomes and resources must be sought between parties. Future-Focused Finance's Close Partnering* action area provides a selection of tools and resources to facilitate partnership working between finance, clinicians and patients and the public.
Get It Right First Time is a clinically-led programme which is helping to improve the quality of care within the NHS by reducing unwarranted variations, bringing efficiencies and improving patient outcomes. By applying all of these value principles and seeking to ultimately improve outcomes, the NHS will also save money.
BPV uses all of these principles to apply a clear, structure process to making effective value-based decisions. Future learning activities will explore elements of each of these value principles.
READING: ‘The Big Idea: How to Solve the Cost Crisis in Health Care’ by Robert Kaplan and Michael Porter via the Harvard Business Review
You can always ask yourself:
Is this activity adding value by improving outcomes for service users?
Is the change we’re proposing in line with value principles?
I hope you've found this learning task useful. Please feel free to contact me with any feedback or post questions by replying to this thread.