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Practical value in the NHS

‘Value’ sounds like a familiar concept but it can mean different things to different people. One definition of value in the health and care sector is ‘health outcomes per dollar spent’, so attempts to increase value can look at either improving quality or reducing cost. The King’s Fund has previously highlighted the fact that addressing waste and variability in clinical work can create better value in the NHS. But what does value mean to people working in the NHS – and how it is being applied in practice?

Experts at our roundtable discussion on this topic – including a chairman, chief executive, chief nurse, deputy chief operating officer, change leader, and representatives of national bodies – agreed that the emphasis should be on patient care. Clinicians are more likely to engage in a programme that revolves around the quality of services, and better care is typically less wasteful, so as one participant put it, ‘if you focus on quality, money will fall out’ [spending will reduce]. Consultants will often drive through successful programmes with change management teams, but we also discussed the role of junior doctors, nurses and therapists, who frequently witness low-value care and understand how to fix it. We know that substantial changes in practice can be delivered as we have seen, for example, in generic prescribing, reduced length of stay and the move towards day case surgery.

We agreed that while it’s always important to optimise patient care by using resources effectively, it is even more topical during a climate of financial rigour. Making this issue relevant to clinicians with competing priorities can be difficult but, in the words of one panel member, it helps to remind people that ‘one doctor’s waste is another patient’s delay’. Indeed errors – and the costs of resolving them – can account for 10 per cent of a hospital’s expenditure, so this is a good place to start when addressing value.

Identifying variations in clinical practice is at the heart of many value programmes (including Right Care, the Model Hospital and GIRFT) so it was interesting to hear different approaches to this issue. Some trusts took the view that it was not practical – or even possible – to make everyone work in a uniform way and that there would still be progress even if only 80 per cent of clinicians follow agreed pathways. Even in hospitals where the choice of devices for hip replacements was tightly restricted, we learnt that it was possible to request an alternative on clinical grounds. National and regional expectations will inevitably frame the discussions about value, but some degree of local flexibility might also be desirable.

Clinical staff and managers need easy access to data that is reliable and regularly updated. Having information down to the level of individual consultants and specialty teams enables clinicians to see the effect of their actions on outcomes or expenditure. People also need time, support and encouragement to change their practice – for instance, we heard about programmes that eventually succeeded but only after the teams were given the space to experiment, fail and learn. Occasionally, ‘pump-priming’ investment helps to launch projects that subsequently yield financial savings.

High-value care means more than just ‘doing things right’, it means ‘doing the right things’, so we should be ready to compare the relative benefits of different services and shift resources accordingly. One problem, though, is that health outcomes can be difficult to measure over many years and across a range of services in health and social care. In our meeting, some of the greatest opportunities for improving value were demonstrated by integrated providers, who were able keep income even when care is transferred to another service.

It certainly helps to have established champions who are driving value initiatives – the examples that we discussed included chief executives, transformation leads and visionary consultants. The influence of the Royal Colleges is critical in guiding doctors to change their practice for the good of their patients. Local populations can also be powerful advocates for improving the value of their services, as long as they are consulted about proposals at any early stage.
Our next step will be to look in more detail at practical approaches to value in the English NHS. We intend to carry out a series of interviews to understand the range of different methods that are currently being used and to learn some of the steps that are necessary to deliver a successful programme.