Heroes Not Zombies

A recent paper in the BMJ has argued that we should focus on the concept of “value” when making decisions about health care and health care spending.

“Value” is a simple concept to describe: useful outcomes divided by the cost of achieving those outcomes

This paper makes a couple of interesting points – not least that “useful outcomes” must be outcomes which are useful to the patient.

Value emphasises the importance of doing whatever we do efficiently. It also highlights the importance of viewing health and disease along a continuum of prevention; of early diagnosis followed by proactive intervention in long term conditions; and of linking healthcare to social care and public health. Most of all it emphasises that what matters to patients and population is not healthcare in itself but health. Healthcare is often a means to health, but it is not the only means. This highlights the importance of establishing a quality numerator in the value equation that truly describes outcomes that matter to patients. We think that quality should encompass clinical outcomes, outcomes reported by patients, and patients’ experiences, measured along whole pathways of care.

Whilst I support this argument and particularly appreciate the emphases on patient reported outcomes and patients’ experiences (which are almost entirely neglected by RCTs based on measurement of a narrow range of biological quantities), I think there’s a crucial missing part of their proposed spectrum of “prevention; of early diagnosis followed by proactive intervention in long term conditions” – health.

If we only start by considering disease and its prevention we will be caught up in an endless pursuit of moving targets. It’s important to be able to reduce the risks of preventable diseases, and it’s also important to treat disease, acute or chronic, but we’re only going to improve the health of the population and reduce the burden of disease if we understand what “health” is, and seek to create the conditions for optimal health.

Value in health care, therefore, has to include policies and processes consciously created to support and develop health, not just to try to prevent or treat disease.