-
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

More of the same is not the answer , not even
better quality, safer, greener cheaper of the
same run by more tightly regulated and
inspected bureaucracies
we need to design, plan and build a new
paradigm to adapt to the challenge of
complexity – “the dynamic state between chaos
and order” Kieran Sweeney (2006)

The Healthcare Archipelago
GENERAL MENTAL
PRACTICE HEALTH
COMMUNITY HOSPITAL
SERVICES SERVICES

JURISDICTIONS INSTITUTIONS
PROFESSIONS
REGULATORS AND INSPECTORS

• Is the service for people with seizures & epilepsy better in Adelaide than
the service in Melbourne?
• Who is responsible for the pelvic pain service for people in North Adelaide?
• How many liver disease service s are there in South Australia and how
many should there be?
• Which service for frail elderly people in Auckland provides the best value?
• How many services are there for people with MusculoSkeletal Disease in
South Australia, and which gives best value?
• Is the variation in outcome for heart failure in the South Australia services
increasing or decreasing?
• Who is responsible for publishing the Annual Report on care for people
with Parkinson’s disease in North Adelaide?
• Is the service the people in our population with atrial fibrillation
 below the minimal acceptable standard
 of high quality, ie in the top quartile
 in the middle of the range (a-b)
BetterValueHealthcare

Population healthcare focuses primarily on
populations defined by a common need
which may be a symptom such as
breathlessness, a condition such as
arthritis or a common characteristic such
as frailty in old age, not on institutions , or
specialties or technologies. Its aim is to
maximise value and equity for those
populations and the individuals within
them

Triple Value Agenda

Allocative efficiency
Cancer
Respiratory
Gastro-intestinal
Between Programme
Marginal Analysis and
reallocation is a Board
responsibility with public
involvement ; the aim is
optimal allocation ie you
cannot get more value
by shifting a single £
from one budget to
another

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

Cancers
Respiratory
Gastro-intestinal
Mental
Health
Many people
have more than
one problem ;
GP’s are skilled in
managing
complexity

Medically
Unexplained
Physical
Symptoms
Homeless
people
Children
Older
People
With four
or more
diagnoses

Cancers
Gastro-instestinal
Respiratory
Obesity
Liver
Gastro
Intestinal
Within Programme,
Between System
Marginal analysis is
a clinician
responsibility

Cancers
MSK
RA
OA/Joints Porosis
Respiratory

Triple Value Agenda

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

Added value
from doing
things right
(quality
improvement)
Higher
Value
Higher
Value
High
Value
Lower
Value
Lower Value
THE INSTITUTIONAL
APPROACH

After a certain level of
investment, health gain
may start to decline
Benefits
Harms
Investment of resources
Benefits - harm
Point of optimality
1. Reduce lower or negative
value activities

Cancers
Respiratory
Gastro-instestinal
Apnoea
Asthma
COPD
(Chronic
Obstructive
Pulmonary
Disease)
Triple Drug
Therapy
O2
Smoking
cessation
Rehabilitation
Within System
Marginal Analysis is a
clinician responsibility
with patient
involvement

Cancers
MSK
RA
OA/Joints Porosis
Replacement
MRI
Arthro
/washout
Respiratory

Hellish Decisions in Healthcare
All people with the condition
People receiving the
specialist service
People who would
benefit most from
the specialist service
3. See the right
patients

High Value Innovation +
Disinvestment from
Lower Value Interventions

Triple Value Agenda

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
Choice Decision
The clinical and social condition of this
patient; other diagnoses, risk factors
and their genetic profile
Personalised and Patient Centred Care

“By patient values we mean the unique preferences, concerns and expectations each
patient brings to a clinical encounter and which must be integrated into clinical
decisions if they are to serve the patient.”
Source: Straus, S.E., Richardson, W.S., Glasziou, P., Haynes, R.B. Evidence-Based
Medicine. (2000) How to practice and teach EBM. (3rd Edition). Elsevier Churchill
Livingstone. (p.1).

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

As the rate of intervention in the population
increases, the balance of benefit and harm
also changes for the individual patient
BENEFIT
HARM
Necessary appropriate inappropriate futile
High value Low value Negative Value

LOW VALUE
(BUREAUCRACY
BASED CARE)
HIGH VALUE
(PERSONALISED &
POPULATION
BASED)
Deliver Care
through
Integrated,
Population-based
Systems
Develop clinical
focus on
populations
Personalise
Care &
Decision -
making
DIGITAL KNOWLEDGE
Change the
Culture to a
collaborative
culture

The Healthcare Archipelago
GENERAL MENTAL
PRACTICE HEALTH
COMMUNITY HOSPITAL
SERVICES SERVICES

Chaos…..….Complexity……...Order
Person aged 87, 5 diagnoses
8 prescriptions, cared for by
Daughter with alcoholic husband
Man aged 67 with
Dukes A colorectal ca.
Man aged 23, Potts#
Football
woman aged 45
invited for cervical
screening
Man aged 57 with
Psychosis, drug dependence, and severe
epilepsy
woman aged 73,
webuser, with T2 Diabetes, STEMI,
high blood pressure, homeopathy
woman aged 67 painful hip &
mild depression

Complex Adaptive Systems
• “Certain nonlinear systems … are commonly
described as being Complex, because their
behavior is defined to a large extent by local
interactions between their components.
When such systems are capable of evolution
they are also known as Complex Adaptive
Systems.”
• Source: Rihani, S (2002) Complex Systems Theory and Development
Practice. Understanding non-linear realities. Zed Books Ltd. (p.7).

SELF CARE
INFORMAL CARE
GENERALIST
SPECIALIST
SUPER
SPECIALIST

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

Hierarchy Network
BetterValueHealthcare

LOW VALUE
(BUREAUCRACY
BASED CARE)
HIGH VALUE
(PERSONALISED &
POPULATION
HEALTHCARE)
Deliver Care
through
Population-based
Systems
Develop clinical
focus on
populations
How to achieve high value through Population and Personalised care

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

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

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 27th out
of the 106 COPD services, and of
greater importance, 6th out of the
23 services in the prosperous
counties

• Is the service for people with seizures & epilepsy better in Adelaide than
the service in Melbourne?
• Who is responsible for the pelvic pain service for people in North Adelaide?
• How many liver disease service s are there in South Australia and how
many should there be?
• Which service for frail elderly people in Auckland provides the best value?
• How many services are there for people with MusculoSkeletal Disease in
South Australia, and which gives best value?
• Is the variation in outcome for heart failure in the South Australia services
increasing or decreasing?
• Who is responsible for publishing the Annual Report on care for people
with Parkinson’s disease in North Adelaide?
• Is the service the people in our population with atrial fibrillation
 below the minimal acceptable standard
 of high quality, ie in the top quartile
 in the middle of the range (a-b)
BetterValueHealthcare

Hierarchy Network
BetterValueHealthcare

OBJECTIVES FOR AN ASTHMA SYSTEM
•To prevent asthma
•To diagnose asthma quickly and accurately
•To slow the process of the disease by effective and safe
treatment
•To help the individual afflicted adapt to the challenges
•To involve patients, both individually and collectively, in
their care
BetterValueHealthcare

•To prevent asthma
•To diagnose asthma quickly and accurately
•To slow the process of the disease by effective and safe
treatment
•To help the individual afflicted adapt to the challenges
•To involve patients, both individually and collectively, in
their care
•To make the best use of resources
•To mitigate inequity
•To promote and support research
•To support the development of staff
•To report annually to the population served
BetterValueHealthcare

LOW VALUE
(BUREAUCRACY
BASED CARE)
HIGH VALUE
(PERSONALISED &
POPULATION
HEALTHCARE)
Deliver Care
through
Population-based
Systems
Develop clinical
focus on
populations
Personalise
care &
decision making
How to achieve high value through Population and Personalised care

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
Choice Decision
The clinical and social condition of this
patient; other diagnoses, risk factors
and their genetic profile
Personalised and Patient Centred Care

LOW VALUE
(BUREAUCRACY
BASED CARE)
HIGH VALUE
(PERSONALISED &
POPULATION
HEALTHCARE)
Deliver Care
through
Population-based
Systems
Develop clinical
focus on
populations
Personalise
care &
decision making
Change the
Culture to a
collaborative
culture
How to achieve high value through Population and Personalised care

“The culture of a group can now be defined as a pattern of shared basic
assumptions that was learned by a group as it solved its problems of external
adaptation and internal integration, that has worked well enough to be considered
valid and, therefore, to be taught to new members as the correct way to perceive,
think, and feel in relation to those problems.”
Source: Schein, E.H. (2004) Organizational Culture and Leadership. John Wiley &
Sons Inc. (p.17).

“Leadership …and a company’s culture
are inextricably interwined.”
Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System
BetterValueHealthcare

ASSESSING THE CULTURE
• Observe the artifacts
• Read the documents
• Speak to informants
BetterValueHealthcare

PrimarySecondaryAcuteCommunityManagerOutpatientHubandSpoke
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
BetterValueHealthcare
Ban old language

Introduce new language eg MUDA

LOW VALUE
(BUREAUCRACY
BASED CARE)
HIGH VALUE
(PERSONALISED &
POPULATION
HEALTHCARE)
Deliver Care
through
Population-based
Systems
Develop clinical
focus on
populations
Personalise
care &
decision making
DIGITAL KNOWLEDGE
Change the
Culture to a
collaborative
culture
How to achieve high value through Population and Personalised care

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