To make the best use of resources, the NHS needs to consider the value of the services it provides, ie, the overall health outcomes achieved in relation to expenditure. Existing budgets can be used to improve the value of care by improving quality (eg, preventing in-patient falls) or reducing expenditure (eg, shortening the length of stay). Alternatively, budgets can be allocated differently, for example, to support better integration of care (potentially looking after more people in their own homes) through accountable care systems.
The opportunities for improving value are wide and varied. A recent report by the OECD, focusing on health care systems in a number of developed nations, estimated that at least 10 per cent of patients are adversely affected by preventable errors and that more than 10 per cent of health expenditure is allocated to correcting such harm. The types of errors cited included low-value care (eg, unnecessary magnetic resonance scans for low back pain), preventable harm (eg, post-operative infections), limited care co-ordination (eg, for long-term conditions or end-of-life care) and poor governance processes. Waste can be reduced either by stopping activities that bring little value or by switching to equivalent but less expensive alternatives.
I am a clinician and at the 2017 King’s Fund Annual Conference, I presented examples of wasteful clinical practice I had observed, which included unnecessary outpatient attendances, inappropriate admissions, delays in specialty assessments and poor communication between neighbouring hospitals. I would challenge any of my colleagues to argue that they don’t have similar examples from their own experience. Estimates of the annual benefits of improving value suggest that £1 billion could be saved by ceasing inappropriate pathology tests, almost £100 million from preventing inappropriate attendances at A&E departments and £300 million from reducing infections associated with hip and knee replacement surgery. Some approaches will require large-scale changes, for example, through the creation of networks or chains of hospitals, but others require incremental adjustments in clinical practice. One example from Next steps on the NHS five year forward view describes simple steps to reduce the incidence of strokes in patients with atrial fibrillation.
Why do clinicians sometimes deliver low value care? Perhaps they have acquired bad habits, become excessively risk averse, are unaware of better alternatives, or work in a system that makes it hard for them to work better despite their best efforts. The good news, though, is that prompting staff to alter their clinical practice – either through guidelines or checklists – or making them more aware of the costs of tests and treatments can help them to deliver better value care.
Risk-averse clinical behaviour (‘defensive medicine’) can be mitigated by bringing patients more fully into the decision-making process. The Choosing Wisely campaign has shown that working closely with patients to discuss the appropriateness of investigations and treatments results in lower levels of intervention. Potentially, this increases the value of care by improving patient satisfaction and reducing unnecessary expenditure. Patient reported measures of experience, outcomes or incidents can also help to indicate where health care is wasteful or dangerous.
Lord Carter’s report highlights areas where the NHS has already succeeded in making savings through the implementation of higher-value care, for example, by switching to equally effective but cheaper generic drugs, reducing the length of hospital stays or developing new approaches that allow day-case surgery. The trust where I work has substantially reduced the number of patients requiring gastroenterology out-patient appointments by triaging all referrals and suggesting investigations and treatment that can be pursued by GPs in the community. Refining the advice and guidance in the eReferral Service makes it easier for GPs and hospital-based specialists to discuss cases, without physically requiring the patient to attend a clinic. The King’s Fund has highlighted other opportunities to improve value by changing clinical practice.
While the government determines the amount of money received by the NHS, clinicians have a duty to ensure that those funds are spent in a way that delivers the greatest value to patients and the public. At The King’s Fund, we have been exploring the different approaches that acute and mental health trusts are taking to achieve higher value care. So far, we have seen that some trusts have used Lean methodologies and national benchmarking data to modify their existing clinical processes, while others have improved clinical outcomes by fundamentally redesigning their services. We will share our findings in conferences and reports later this year.