1. - Progress in the last 40 years has been amazing but all health services, everywhere, still face 5 major problems one of which is unwarranted variation which reveals the other four HARM, from overuse even when quality is high WASTE OF RESOURCES through low value activity INEQUITY, from underuse by groups in high need FAILURE TO PREVENT DISEASE &DISABILITY And new, additional, challenges are developing RISING EXPECTATIONS INCREASING NEED FINANCIAL CONSTRAINTS CLIMATE CHANGE Variation in utilization of health care services that cannot be explained by variation in patient illness or patient preferences. Jack Wennberg

2. More of the same is not the answer, not even better quality, safer, greener cheaper of the same we need to design, plan and build a new paradigm

4. What do we want to achieve? High Value Healthcare which Allocates resources for optimal value & equity Makes optimal value from the use of allocated resources Ensures each individual receives care that addresses their particular problem and values

5. Triple Value Programme Individual & Personalised Allocative, Technical, resources distributed resources used to optimise value to best effect

6. Cancer Respiratory Gastro- intestinal Mental Health Between Programme Marginal Analysis and reallocation is a commissioner responsibility with public involvement

7. Cancers Respiratory Gastro- intestinal Mental Health Many people have more than one problem or may have an ill defined symptom ; GP’s are skilled in managing complexity

8. Cancers Respiratory Gastro- instestinal Apnoea COPD (Chronic Obstructive Pulmonary Disease) Asthma Within Programme, Between System Marginal analysis is a clinician responsibility Breathlessness

9. Technical Value = Outcomes / Costs Outcome= Benefit (EBM +Quality) – Harm (Safety ) Costs (Money + time + Carbon)

10. Cancers Respiratory Gastro- instestinal Apnoea COPD (Chronic Obstructive Pulmonary Disease) Asthma Triple Drug Therapy Rehabilitation O2O2 Smoking cessation Within System Marginal Analysis is a clinician responsibility with patient involvement

11. The law of diminishing returns Benefits Investment of resources

12. Harmful effects increase in direct proportion to the resources invested Harmful or Side effects Of care Investment of resources

13. After a certain level of investment the health gain may start to decline; the point of optimality Benefits Investment of resources Harms Benefits - harm

14. Evidence, Derived from the study of groups of patients The values this patient places on the problem that matter most to them, and on benefits & harms of the options The clinical and social condition of this patient; other diagnoses, risk factors and their genetic profile Choice Decision Personalised and Stratified Medicine

15. The Healthcare Archipelago GENERAL MENTAL PRACTICE HEALTH COMMUNITY HOSPITAL SERVICES

16. The Commissioning Archipelago GP/ Pharmacists/ optometrists Public Health Specialist commissioning 211 CCG’s152 Local Authorities

17. SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST

18. This is an example of a national service set up as a system

19. BetterValueHealthcare Hierarchy Network

21. Implications for the professions population based system designers and co-ordinators knowledge managers, for patients and clinicians (blood in; knowledge out uncertainty in; knowledge out )

22. Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and provided evidence based, patient centred care, and to improve effectiveness, productivity and safety

23. Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit from the knowledge of her team

24. Dr Jones is given 1 day a week for Population Respiratory Health and the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources for Working with Public Health to reduce smoking Network development Quality of patient information Professional development of generalists, and pharmacists Production of the Annual Report of the service She is keen to improve her performance from being 27 th out of the 106 COPD services, and of greater importance, 6 th out of the 23 services in the prosperous counties

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