3. We have had 2 healthcare revolutions, with amazing impact
The First was the public health revolution
The Second has been the technological revolution supported by 50 years of increased investment & 20 years of evidence based medicine, quality and safety improvement eg
Antibiotics
MRI & CT
Coronary artery bypass graft surgery
Hip & knee replacement
Chemotherapy
Radiotherapy
Randomised controlled trials
Systematic reviews

4. after 50 years of progress all societies still face three massive problems.
The first is unwarranted variation in healthcare ie ”Variation in utilization of health care services that cannot be explained by variation in patient need or patient preferences.”
Jack Wennberg
Variation reveals the other two problems

6. The first is Underuse of high value interventions which results in
1. Preventable disability and death eg if we managed atrial fibrillation optimally there would be 5,000 fewer strokes and10% reduction in vascular dementia,(2012) and
2. inequity
This was in the NHS Atlas of Variation

7. The second is overuse which 1. always wastes resources and 2
The second is overuse which 1. always wastes resources and 2. can cause harm
BENEFIT
Effect
Size
The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio
One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality.
This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICUTE IN HEALTHCARE
Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce
Antibiotics
Chemptherapy ion the last week of life
Elderly people with multiple disorders dying in intensive care
Rarely do the comment on
The last 10% in the increase in imaging ( going up at 8-10% per year)
The last 10% in the increase in lab testing ( going up at 8-10% per year)
Emphasise THIS HAS NOTHING TO DO WITH MONEY
[raise the choosing wisely campaign amd the BMJ’s too Much medicine
Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency
Medical Knowledge
Patient care
Professionalism
Interpersonal and communication skills
Practice-based learning and improvement
Systems-based practice
Proposed new competency: cost-conscious care and stewardship of resources
Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:
Resources

8. BENEFIT HARM Effect Size Resources
The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio
One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality.
This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE
Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce
Antibiotics
Chemptherapy ion the last week of life
Elderly people with multiple disorders dying in intensive care
Rarely do the comment on
The last 10% in the increase in imaging ( going up at 8-10% per year)
The last 10% in the increase in lab testing ( going up at 8-10% per year)
Emphasise THIS HAS NOTHING TO DO WITH MONEY
[raise the choosing wisely campaign amd the BMJ’s too Much medicine
Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency
Medical Knowledge
Patient care
Professionalism
Interpersonal and communication skills
Practice-based learning and improvement
Systems-based practice
Proposed new competency: cost-conscious care and stewardship of resources
Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:
Resources

9. BENEFIT HARM BENEFIT -HARM Effect Size Resources UNDERUSE OVERUSE
The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio
One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality.
This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE
Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce
Antibiotics
Chemptherapy ion the last week of life
Elderly people with multiple disorders dying in intensive care
Rarely do the comment on
The last 10% in the increase in imaging ( going up at 8-10% per year)
The last 10% in the increase in lab testing ( going up at 8-10% per year)
Emphasise THIS HAS NOTHING TO DO WITH MONEY
[raise the choosing wisely campaign amd the BMJ’s too Much medicine
Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency
Medical Knowledge
Patient care
Professionalism
Interpersonal and communication skills
Practice-based learning and improvement
Systems-based practice
Proposed new competency: cost-conscious care and stewardship of resources
Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:
Resources
POINT OF
OPTIMALITY
UNDERUSE OVERUSE

10. NHS or nHS?
Is the service for people with seizures & epilepsy in south East London better than the service in North West?
Who is responsible for the service for people with dementia in Southwark ?
How many liver disease services are there in London and how many should there be?
Which service for people at the end of life in London provides the best value?
Is the service for people with type 2 diabetes in London better than the service in Manchester?

11. In the next decade need and demand will increase by at least 20 % so what can we do? Well, we need to continue to 1. Prevent disease, disability, dementia and frailty to reduce need 2.Improve outcome by provide only cost-effective, evidence based interventions 3. Improve outcome by increasing quality and safety of process 4. Increase productivity by reducing cost These measures reduce need and improve efficiency BUT we also need to increase value

12. The Aim is triple value Personal value, Allocative value ,
Personal value,
Allocative value ,
Technical value ,
It is useful to emphasise that there are two types of value , allocative and technical relate primarily to populations, personalised to the individual
This report from the academy of medical royal colleges in 2015 calls for a culture of stewardship
waste is anything that does not add value and as the Academy’s re[port emphasises we need to develop a ‘culture of stewardship’ to ensure the NHS will be with us in 2028 and 2038

13. FOR EXAMPLE , AVERAGE DURATION OF STAY FOR KNEE REPLACEMENT
Productivity
Outputs/Costs

14. Efficiency Productivity Outcomes/costs Outputs/Costs FOR EXAMPLE,
% OF PATIENTS WHO HAVE A KNEE REPLACEMENT AND REPORT THAT THE OUTCOME IS GOOD OR VERY GOOD v
Efficiency
Outcomes/costs
Productivity
Outputs/Costs

15. Technical Value Efficiency Productivity Are the right patients being
seen or is there either harm from
over diagnosis or
2. inequity from
underuse v
Efficiency
Outcomes/
Resources
Productivity
Outputs/
Resources
Quadruple Resources
Financial
Environmental (carbon)
Social
Time, not only clinician time but also time of patients and carers

16. Personal value isdetermined by the value the individual places not only on
the outcomes of their treatment, both beneficial and harmful, related to the problem that was bothering them most but also to
the investment they have made , for example the time they have spent and their experience of care and decision making

19. THE Better Value Healthcare METHOD OF INCREASING VALUE FOR POPULATIONS
Be clear about which population is being served
Shift 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
Develop population based systems that not only deliver high quality care efficiently but also
Address the needs of all the people in need,
Implement high value innovation funded by reduced spending on lower value intervention
Increase rates of higher value intervention funded by reduced spending on lower value intervention eg shift resources from treatment to prevention

20. 2. Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity

21. ANNUAL SPEND PER MILLION”
Cardio £100M
Respiratory £78M
Gastro-
Intestinal
£68M
Eyes
&
vision
£30M
Mental health £11 Bn directly, perhaps another £5 Bn in hidden costs of people with physical problems with significant psychological factors at this point participants will say , rightly, that lots of people have more than one condition , so move on to the next slide
ANNUAL SPEND PER MILLION 21

22. ANNUAL SPEND PER MILLION”
Mental Health
£145M
Cardio £100M
Respiratory £78M
Gastro-
Intestinal
£68M
Mental health £11 Bn directly, perhaps another £5 Bn in hidden costs of people with physical problems with significant psychological factors at this point participants will say , rightly, that lots of people have more than one condition , so move on to the next slide
Eyes
and vision
£30M
ANNUAL SPEND PER MILLION 22

23. 2. We are working to develop programme budgets determined by characteristic such being elderly with frailty
Mental
Health
Many people have more than one problem ; they have complex needs.
GP’s are skilled in managing complexity but when one of the problems becomes complicated the Generalist needs Specialist help
Cancers
Respiratory
Gastro-
intestinal
You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 23

24. Rhythm CVD Neurology Gastro- instestinal STEMI Coronary Disease Heart
Failure
Rhythm
CVD
Neurology
Gastro-
instestinal
The first point is to point out that allocative decisions are also made within each system of care and and there was an excellent piece of work done by the london respiratory clinical community using the STAR tool to move resources from triple drug therapy to smoking cession and rehabilitation. Now ask the group what they would do if asked to fund more resources for glaucoma and use the next ppt 24

25. Rhythm CVD Neurology Gastro- instestinal STEMI Coronary Disease Heart
Failure
Rhythm
CVD
Neurology
Warfarin
DOACs
Gastro-
instestinal
Ablation
The first point is to point out that allocative decisions are also made within each system of care and and there was an excellent piece of work done by the london respiratory clinical community using the STAR tool to move resources from triple drug therapy to smoking cession and rehabilitation. Now ask the group what they would do if asked to fund more resources for glaucoma and use the next ppt 25

26. Warfarin
Drugs
Warfarin
drugs
DOACs
Warfarin clinics
Warfarin
drugs
Clinics
clinics
Genomics
DOACs

28. Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental
Health
Cancers
Respiratory
Gastro-
intestinal
You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 28

29. Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental
Health
Cancers
Respiratory
Gastro-
intestinal
You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 29

30. Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental
Health
Cancers
Respiratory
Gastro-
intestinal
You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 30

33. THE Better Value Healthcare METHOD OF INCREASING VALUE FOR POPULATIONS AND INDIVIDUALS IS BY
Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered
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
Develop population based systems that not only deliver high quality care efficiently but also
Address the needs of all the people in need, with the specialist service seeing those who would benefit most
Implement high value innovation funded by reduced spending on lower value intervention
Increase rates of higher value intervention funded by reduced spending on lower value intervention eg shift resources from treatment to prevention

34. All people with the condition People People who receiving
The service
People who
would benefit
most from the
service
Here isan example of the type of problems that clinicians need to tackle , particulatrly because … next ppt

35. All people with the condition who do not need to see the
specialist service practice healthcare supported by generalists who are
themselves supported
by specialists
The right
People
receiving
the specialist
service
Here isan example of the type of problems that clinicians need to tackle , particulatrly because … next ppt

36. TECHNICL VALUE AFTER THE RESOURCES HAVE BEEN ALLOCATED
Effect
Size
BENEFIT
HARM
BENEFIT -HARM
The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio
One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality.
This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE
Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce
Antibiotics
Chemptherapy ion the last week of life
Elderly people with multiple disorders dying in intensive care
Rarely do the comment on
The last 10% in the increase in imaging ( going up at 8-10% per year)
The last 10% in the increase in lab testing ( going up at 8-10% per year)
Emphasise THIS HAS NOTHING TO DO WITH MONEY
[raise the choosing wisely campaign amd the BMJ’s too Much medicine
Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency
Medical Knowledge
Patient care
Professionalism
Interpersonal and communication skills
Practice-based learning and improvement
Systems-based practice
Proposed new competency: cost-conscious care and stewardship of resources
Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:
Resources
POINT OF
OPTIMALITY
UNDERUSE OVERUSE

37. BENEFIT HARM The Effect Size Resources CLINICAL VALUE ECONOMIC VALUE
The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio
Resources
CLINICAL
VALUE
ECONOMIC VALUE
Necessary appropriate inappropriate futile
Higher lower low Zero Negative

38. Deliver Care through high quality Systems
Develop clinical focus on populations
IMPROVED OUTCOMES WITH NO MORE MONEY FOR BOTH
INDIVIDUALS &
POPULATIONS
LOW VALUE
BUREAUCRACY BASED CARE
DIGITALLY MANAGED KNOWLEDGE
Personalise
Care &
Decision -making
Create a collaborative
Culture of
stewardship

41. The Care Archipelago GENERAL MENTAL COMMUNITY PRACTICE HEALTH SERVICES
SOCIAL HOSPITAL
CARE SERVICES
COMMUNITY
SERVICES
Probably do this and the next ppt quite quickly showing the impossibility of solving the problems of healthcare through the bureaucratic approach alone
Emphasise that bureaucracies have an important role to play , but only to ensure the fair and open employment of staff and the uncorrupt management of money ; they cannot solve complex problems like providing better care for people with epilepsy

42. The Professional Archipelago
NURSES
DOCTORS
PHYSIOS
Probably do this and the next ppt quite quickly showing the impossibility of solving the problems of healthcare through the bureaucratic approach alone
Emphasise that bureaucracies have an important role to play , but only to ensure the fair and open employment of staff and the uncorrupt management of money ; they cannot solve complex problems like providing better care for people with epilepsy
PSYCHOLOGISTS
OTs
FINANCE

43. The Commissioning Archipelago
152
Local
Authorities
211 CCG’s
GP/
Pharmacists/
optometrists
You can point out that even small and straightforward health challenges , like deafness in children have four different types of commissioner involved
Public
Health
Specialist
commissioning

44. SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST

45. SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST
SUPER

46. TYPES OF CARE BUREAUCRACIES SELF CARE INFORMAL CARE e.g family
GENERALIST
(primary)
SPECIALIST
(secondary)
SUPER
CCG Spec NHSE PHE Trust LA GPs
STP Com
BUREAUCRACIES

47. PROGRAMMES AND SYSTEMS FOR POPULATIONS DEFINED BY NEED,
eg PEOPLE WITH…
Mental health problems
Frailty
Cancer
Eye problems
TYPES OF
CARE
SELF CARE
INFORMAL CARE
e.g family
GENERALIST
SPECIALIST
SUPER
CCG Spec NHSE PHE Trust LA GPs
STP Com
BUREAUCRACIES
How many population based networks are there for people with heart failure in London?

48. CHOOSING CRITERIA & SETTING STANDARDS
It took several years to develop because sickle cell is a complex problem, for example in some parts of the country the condition is so uncommon that many professionals were unfamiliar with it.
Having formulated objectives and chosen criteria to measure those objectives, the next stage in the development of a system is to set standards. (Standards can be set for process criteria even in the absence of outcomes.)
Donabedian, in many ways the founder of the healthcare quality movement, said in a lecture that ‘the quality of a health service is the degree to which it conforms to pre-set standards of goodness’.
When setting standards, it is important to be aware that standards are subjective, and different perspectives exist. A manager may think a service is of good quality, but patients and carers may regard its quality as poor, or vice versa. Many people rate their experience with alternative or complementary medicine as high in quality, whereas many clinicians would regard the service provided as low in value.
It is often useful to set more than one level of standard. In a book popular in the 1990s entitled In Search of Excellence people were exhorted to be excellent. However, exhortations to excellence can be de-motivating to people working in difficult circumstances aware that excellence is the result not only of hard work but often of the chance coalition of skilful individuals working in a propitious environment. For this reason, it is advisable to set three levels of standard:
a minimal acceptable standard, below which no programme of care should fall;
an excellent standard, which is reached by the best; and
an achievable standard, for example the cut off point between the top quartile and the rest
This is an example of a national service set up
as a system

49. Hierarchy Network
The network is the set of individuals and organizations that delivers the system to the populations.
It is useful to go through the hierarchy of the 20th century to the network of the 21st century, with the patient at the centre
“professor, specialist and GP, with the patient invisible”
In the 21st century all the professionals, all the nodes in the network are of equal importance with the patient in the middle

51. Map of Medicine - COPD
Work like an ant colony; Neither markets nor bureaucracies can solve the challenges of complexity

52. Ban old language Introduce new language
AcuteCommunityManagerOutpatientHubandSpoke
Introduce new language
A SYSTEM is a set of activities with a common set of objectives and outcomes; and an annual report. Systems can focus on symptoms, conditions or subgroups of the population
(delivered as a service the configuration of which may vary from one population to another ) A NETWORK is a set of individuals and organisations that deliver the system’s objectives
(a team is a set of individuals or departments within one organisation) A PATHWAY is the route patients usually follow through the network
A PROGRAMME is a set of systems with ha common knowledge base and a common budget
Now introduce the new language
Here are the new terms
Acute and community implies the hospital is not part of the community
Primary and secondary ignores the point that A&E is for many people their primary port of call
Out patients is a 19th century term
Hub and spoke implies a power relations hip; in a network all the constituent elements are nodes

53. We need a new set of skills and tools what is the relationship between value and efficiency? What is the relationship between value and quality ? what is meant by the optimal use of resources? How would you assess the culture of an organisation? What is a system and what is a network? What is the relationship between a system and a service?

54. ABILITY THERE IS NO STABLE PHASE IN LIFE BIOLOGICALLY THE TURNING
POINT
Best possible rate of decline due to ageing
alone
ABILITY
Development Ageing
THERE IS NO STABLE PHASE IN LIFE BIOLOGICALLY

55. ABILITY AGE THE TURNING POINT THE FITNESS GAP
Best possible rate of decline
Actual rate of decline
ABILITY
AGE

56. THE
TURNING
POINT
THE
FITNESS
GAP
Best possible rate of decline after onset of heart failure
ABILITY
The Line
THE LEVEL REQUIRED TO GET TO
THE TOILET IN TIME
Rate of decline after onset of heart failure
AGE
ONSET OF
HEART FAILURE
THE FITNESS GAP OFTEN GETS WIDER FASTER AFTER THE ONSET OF A LONG TERM CONDITION, AND MAY DRAG THE PERSON BELOW THE LINE

57. AGEING DISEASE
LOSS OF BELIEFS,
FITNESS ATTITUDES &
EMOTION

58. ABILITY AGE The Line THE TURNING POINT THE FITNESS GAP
Best possible rate of decline after onset of heart failure
ABILITY
The Line
THE LEVEL REQUIRED TO GET TO
THE TOILET IN TIME
Rate of decline after onset of heart failure
AGE
ONSET OF
HEART FAILURE

59. ABILITY
AGE
Best possible rate of decline after onset of heart failure
The Line
LEVEL OF ABILITY
REQUIRED TO GET TO
THE TOILET IN TIME
NARROWING OF THE FITNESS GAP AND PREVENTION OF LOSS OF ABILITY TO GET TO THE TOILET IN TIME
AS RESULT OF TRAINING
AT ANY AGE AND WITH ANY NUMBER OF LONG TERM CONDITIONS PEOPLE CAN IMPROVE FITNESS AND STAY ABOVE THE LINE

60. THE KEY DOCUMENT WAS PRODUCED BY THE ACADEMY OF MEDICAL ROYAL COLLEGES IN 2015

62. THE BENEFITS OF ACTIVITY THERAPY, Activity Therapy
AFFECTS THE DISEASE PROCESS DIRECTLY IN SOME CONDITIONS
PREVENTS THE LOSS OF FITNESS AND ACCELERATED DECLINE THAT OFTEN FOLLOWS DIAGNOSIS
REDUCES THE RISK OF OTHER LONG TERM CONDITIONS EG REDUCING THE RISK OF HEART DISEASE AND DEMENTIA
MAKES PEOPLE FEEL BETTER