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Healing Health Services

February 26, 2014

The Great and the Good of the English health & social care scene gathered in London on 22 January to hear a keynote presentation by Professor Michael Porter of the Harvard Business School, on the theme of “Value-Base Health Care Delivery”.

Professor Porter is much in demand as a health services analyst and policy advisor, not only here in the UK, but also in the USA, and in other European countries, notably Germany and Sweden.

He had much to say that was compelling and persuasive about the current problems facing all health systems – not just the NHS.  But his talk was as interesting for what it didn’t address, as for what it did: and the talk was very interesting.

All developed countries have an existing health infrastructure, and all are based on a legacy of organizational structures, medical science, management practices, models of patient mobility and payment models that are now obsolete.  All countries are struggling to optimize the efficiency of their health care systems in the face of rising demand – due to demography, advances in medical science and technology, and the rise of chronic conditions; and they are doing so in the face of major pressures on public spending.  He steered clear of the issue of charging, on which SAMI commented in a January blog, see https://samiconsulting.wordpress.com/2014/01/10/a-cure-for-the-nhs-cold/

Professor Porter’s response to this is what he calls a Value-Based Health Care Delivery System.  This is based on the keystone principle of:

Value  =  Health outcomes that matter to patients

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the costs of delivering the outcomes.

He identifies six steps to achieving this system:

1.  Organize care into integrated practice units based on patient medical conditions, with services based on condition-specific diagnostics and expertise, rather than, as now, generic diagnostic services and broad, generic professional specialisms.  This will create a virtuous circle of greater experience, leading to greater expertise, better outcomes, and more cost-effective processes.

2.  Measure outcomes and costs for every patient this will confirm that low volume equals low value.  Studies in Baden-Wurtemberg, in Germany show that the mortality rate for low birthweight babies born at under 26 weeks is 33.3% in general maternity units, but just 15% in its five specialist units.

The principle of measuring outcomes that matter to patients is illustrated by a similar study of outcomes in prostate cancer in Germany, where the survival rates are almost identical in the best hospital and the average for all hospitals (95% to 94%), but there is a clear difference in other outcomes.  In the best hospital, the rate of severe erectile dysfunction after one year is 17.4%, and the rate of incontinence after one year is 9.2%. The averages across all hospitals are 75.5% and 43.3% respectively.  I know where I’d choose to be treated!

3.  Move to bundled payments for care cycles.  In Sweden, the tariff for hip and knee replacements now covers not only the cost of pre-admission, the procedure and the hospital stay, but also rehab, the cost of any additional surgery in the following two years, and post-operative infections over the next five years: this is a powerful incentive to get things right!

4.  Integrate care delivery systems, concentrating services in fewer locations, but also shifting routine work out of specialist centres to smaller facilities.  This has happened with cancer services in England, and stroke services in London.

5.  Expand geographical reach.  The Cleveland Clinic in Ohio now has eight affiliates providing cardiac and kidney surgery in other states of the US.  And here in the UK, Moorfields, which leads the world in ophthalmology and eye health research, has established a “franchise” of accredited services (including some overseas branches), with Moorfields itself as the hub.

6.  Build an enabling IT platform, encompassing the full care cycle, and allowing access to all involved parties, including patients.

It is worth noting that very little (maybe none) of what Professor Porter is saying is new.  The ideas of greater integration, specialization, outcomes measurement, and integrated IT have been current for at least 20 years. But there is a huge inertia in all health systems, much of it due to the burden of the legacy of established systems, professional demarcation, learned clinical practice, financial barriers etc.  More encouragingly, there is evidence that the best commissioning groups in the NHS are starting to take up the challenge.

So what didn’t Professor Porter say?

His lecture addressed the policy problems of the here and now.    What he didn’t address was what lies ahead.  Health technologies will see the development of more personalized treatments, based on genetic and stem cell medicine.  This in turn will strengthen the importance of partnership with patients, and patient involvement in their care.

These techniques – which are already well in train – will also permit earlier diagnosis, and even pre-diagnosis of illness, again emphasizing the value of partnership with patients in screening and preventing or mitigating the early onset of illness and maintenance of good health.

The good news is that these developments are likely to move us further in the direction mapped out by Professor Porter.  But health service professionals, planners and managers, need to be looking at these developments, and taking them properly into account in planning the strategic development of services.  SAMI is here to help.   Applying future scanning technologies, SAMI can help health services commissioners and providers to start to envisage the sort of service they need to be working towards.  An example can be seen in the report on the “Blowing the Cobwebs From your Mind event , which looked at the future of the pharmaceutical industry: https://samiconsulting.wordpress.com/2013/11/21/blowing-the-cobwebs-off-your-mind-2/

Written by David Lye

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