“There is a general feeling that there is something not quite right in healthcare,” says Sally Lewis, assistant medical director, NHS Wales. “There is both over-diagnosis, under-diagnosis and unmet need at a time when healthcare systems are strapped for cash and demand is rising. We are not always directing healthcare resource to the right places.”
Lewis, a GP who heads up the value-based healthcare team at the Aneurin Bevan University Health Board in South Wales, has a long-standing interest in maximising the impact of health budgets. Inspired by the work of Harvard professor Michael Porter and Oxford-based policy expert Muir Gray, she was keen to develop a culture of defining and measuring patient outcomes in the Welsh health system.
“Clinicians tend to default to action,” she says. “And once patients are on a particular pathway they tend to accelerate along that trajectory in line with guidelines. This is not always in patients’ best interests but if we could get better shared decision-making and consider how best to achieve the patient’s own health goals we might get better results. In order to do this we need to furnish people which much better information that is directly relevant to them.”
In some cases, this could mean avoiding interventions, such as taking medicines or having surgery, that carry risks which patients might prefer not to take, thus reducing costs and the potential for harm.
“Healthcare is an inherently risky business,” said Lewis. “If we can tell patients that other people like them have certain outcomes following particular interventions it can be a powerful way to support shared decision-making, by helping people weigh up their options.”
This line of thinking led Lewis to embrace ‘Prudent Healthcare’, an initiative launched three years ago by the Welsh government. With echoes of the Realistic Medicine programme in Scotland, Slow Medicine in Italy and some overlap with the Royal College of General Practitioners Over-diagnosis Group, it opened the door to greater scrutiny of how budgets could be better spent.
Winning hearts and minds
Agreeing to define and measure outcomes is no easy task. Lewis has invested two years working with colleagues to bring about the cultural shift that is essential to changing how the health system works. Then the team had to devise and procure the information technology system needed to capture and analyse patient data, but the first step was getting clinicians on board.
“This is a new way of doing things so there is bound to be resistance – you’ve got to win hearts and minds,” Lewis says. The biggest source of scepticism from doctors stemmed not from a lack of faith in the patient-centric approach but in the staying power of Lewis and her team. Reform-weary clinicians had seen plenty of pilot projects pitched by enthusiastic colleagues who run out of steam, budget or political support within a few months.
“There was a huge trust issue at the beginning,” Lewis says. “Some doctors thought there would be no follow through so we needed to prove ourselves by working with early adopters.”
The big carrot for participating clinical teams was the promise of additional resources for their services: where savings can be made, doctors would have the opportunity to influence how funds were reinvested for the good of their patient population.
For example, pulmonary rehabilitation can be valuable for patients with chronic obstructive pulmonary disease (COPD) but tends to get too little investment. Lewis’s team found that “all roads lead to inhaled therapies” which might not improve outcomes but cost a lot. They challenged respiratory consultants and GPs responsible for the COPD population to rethink how they manage their patients. Doctors were asked to focus on delivering the outcomes individual patients desired, rather than rigidly following a fixed care pathway.
The result has been significant savings for the drugs bill, with better results for patients. The savings encouraged the health board to invest more in pulmonary rehabilitation – something respiratory physicians had long sought. “After that I had clinicians banging down my door because suddenly they could see how this approach worked for everyone.”
The British Lung Foundation (BLF) has worked with the health board representing the voices of patients. “The traditional model of continually prescribing more and more inhalers fails patients and it costs a fortune to the NHS,” said BLF’s head in Wales, Joseph Carter. “By looking at the whole pathway of the condition, changing inhalers and investing money in pulmonary rehabilitation, smoking cessation and supporting people after discharge, the health board can improve patient experiences and long term outcomes.”
On the structural side, breaking down budgeting silos is a major challenge. While the health service is integrated – connecting primary care with the hospital system – taking a holistic, patient-centric approach is not straightforward.
For example, if extra spending in primary care saves hospitals money, or delivers savings over several years, it can be challenging to make the money follow the patient. “Even in an integrated service the silos are huge,” Lewis said. “Nobody wants to transfer funds to another part of the service. It is also hard to account for preventative measures where payback is significant but takes several years; it’s human nature to focus on the immediate future.”
Creating new and burdensome administration that goes nowhere would guarantee the failure of the whole project. The value-based healthcare team worked with clinicians to secure their buy-in, discussing why outcomes are being tracked and what would be done with this intelligence.
“Sometimes PROMS [patient-reported outcome measures] programmes focus only on what to measure and how to measure it, rather than thinking about why they do it and what actions could follow,” says Lewis. “The other problem can be that the PROMs data remains isolated from other clinical data that would allow robust analysis at a local level.”
A case in point is tracking outcomes in inflammatory bowel disease (IBD) to optimise patient management and make the service more efficient. Many IBD patients are stable and do not need or want to come to outpatient clinics for check-ups when they are well. If they can remotely input their data, allowing a doctor to review it and give them a virtual confirmation that all is in order, they are spared a trip to the hospital and the clinic frees up time and resources for patients experiencing disease flares.
As examples stack up of how the value-based approach can bring efficiencies while improving patient satisfaction, the idea is beginning to spread throughout the health system.
The procurement department has been prompted to take a more long-term view of value-for-money. “Instead of buying the cheapest lens for cataract surgery, they want to look not just at price but also at how long the lens lasts,” explains Lewis. “If, for example, one lens is the cheapest up front, but fails more quickly and more often than its competitor, how do we factor that outcome into a contracting discussion with a medical devices company?”
Outcomes measures have also been embedded in services for Parkinson’s disease patients, orthopaedic care, diabetes clinics and stroke units. With the health board now investing in a new IT system to support data collection and analysis, the prospects for system-wide adoption of outcome-driven care are good.
“It has taken 18-24 months to get to the point where we can make the case for investing in an IT system to allow us to do this properly,” says Lewis. “We had to work with people throughout the system and show what can be achieved. If I’d gone in on day one and requested half a million pounds for an IT system I might have been laughed out of the room.”