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Don Redding, of National Voices, discusses the organisation’s Realising the Value programme and summarises the available concepts of value, and their appropriateness for the Five Year Forward View world
Slowly but surely, efforts are under way in the NHS to bring greater focus to questions of ‘value’ rather than just financial efficiency. But notions of value are not simple, and they can be contested. The Realising the Value programme, funded by NHS England, completed its work in November and has published a series of reports and resources, whose theme is the ‘value’ experienced and created by people and communities acting in pursuit of health and well-being.
This includes a conceptual report, New approaches to value in health and care, that argues for a new, consensus-based set of outcomes, based on what matters most to people (not systems), to be shared across all sectors of health and social care, including the voluntary and community sector.
A new relationship
Chapter 2 of the Five Year Forward View states that the goals of the whole document will depend on forging a new relationship with people and communities, mobilising their energies and assets for prevention, for better management of health, and to safeguard the sustainability of the healthcare system.
It is an updated version of the Wanless report’s conclusion that only a scenario where people are ‘fully engaged’ in their health will enable demand to be balanced with available resources. It recognises what decades of research have shown (and Realising the Value updated and interrogated this evidence): that where people are more involved in their health and care, we achieve better outcomes and a more appropriate use of healthcare resources.
People and communities
A first step towards the Chapter 2 aim is to understand that people and communities themselves create and contribute value. Individually, we make daily decisions about our health and how to manage it, in the context of our lives and circumstances. These include decisions about diet, exercise, stress and anxiety, and whether to take part in social and cultural activities; and also about how to manage existing conditions, whether and how to adhere to treatments and monitoring, and when and where to use health services.
As Wanless concluded: “For every £100 spent on encouraging self-care, around £150 worth of benefits can be delivered in return.”
Individuals also care for others. Over six million people are involved in informal caring, a quarter of them full time, with its value estimated at £132 billion a year – greater than the NHS budget. They are the biggest ‘workforce’, and arguably the ‘primary care system’.
People volunteer, with a quarter of adults doing so regularly. Its value is calculated by the Office of National Statistics at £24 billion a year.
Collectively, people have created a vibrant and resourceful voluntary and community sector: 163,000 organisations, with assets of over £100 billion, a workforce of 827,000, and a ‘gross value added’ contribution to the economy of over £12 billion a year.
Of course not all that this sector does is related to health and care, but much of its can be related to supporting well‑being. These forms of value creation are rarely recognised by the value frameworks used in the NHS, whose focus has always been on its own budgets, as if these were somehow the source of health.
Nor does the formal sector’s accounting adequately recognise what happens in ‘coproduction’. An individual who actively takes care of his or her own health is ‘producing’ health. Where they interact with the formal health service, making decisions together with professionals, they are ‘co-producing health’.
Likewise, community activity that supports people’s well-being helps to produce health; and where the formal and informal sectors cooperate in this, they are ‘co-producing health’. Historically, however, the NHS has been poorly equipped to make decisions about investment based on what it can achieve in coproduction.
That might mean, for instance, using Social Return on Investment methods and prioritising the engagement of people and communities over, for example, individual treatments and procedures, or the maintenance of NHS institutions.
It could mean unlocking funds for ‘social innovation’ – the joint production of effective community based schemes for supporting health and well‑being – rather than always thinking innovation is about drugs and technology.
Current NHS responses
As leaders and policy makers in the NHS have begun to shift direction towards population health approaches, and their incipient delivery through vanguards and accountable care organisations, the limitations of traditional financial approaches have been recognised.
The Future Focused Finance (FFF) programme and the Right Care programme both explicitly seek to shift from a focus on cost to a focus on value. FFF’s Best Possible Value work draws heavily on Michael Porter’s work, which argues for an emphasis on whole system outcomes rather than those from specific single episodes of care.
But Porter still assumes that this ‘whole system’ works by completing identifiable ‘cycles of care’. Arguably this is outdated when 70 per cent of NHS resources are being used by people with long term conditions that are not going to be ‘cured’.
Moreover, it is still looking solely at service inputs and outcomes – not at what people are doing in coproduction, or how community approaches might divert or prevent use of the formal system in the first place.
The Right Care programme recognises the value of involving people in two ways: that sharing treatment decisions creates better value; as does that personalised care for a small number of ‘complex’ (ie costly) patients. But the overwhelming focus of its Commissioning for Value work has been in driving out variation in the value of spend on single disease pathways.
For the full Forward View world, we need to be looking for something wider than these approaches, as we described in this table: www.nesta.org.uk/publications/new-approaches-value-health-and-care.
A full cross system approach
The published frameworks for the PACS and MCP new care models show the direction of travel: to place-based, population focused health services, integrated with other services, and closely engaged with people and communities.
In this future, ‘whole system outcomes’ are those produced by a range of services (public health and social care as well as the NHS) and individuals and communities acting together. When considering and capturing value, therefore, we need to look at what matters to all stakeholders; and at outcomes in several dimensions – such as social and economic impacts, and well-being, not only ‘health’.
There is some dawning recognition of this. The leaders of all the national system leading bodies have signed a shared commitment to engaging and empowering communities that includes the intention to develop a simpler set of shared outcomes; and stakeholders including the NHS Confederation, NHS Clinical Commissioners and the Academy of Medical Royal Colleges have called for a single outcomes framework for integrated care systems.
Our paper, New approaches to value… makes concrete recommendations for developing a single, cross system outcomes framework based on what matters most to people and communities. And as a first step, working closely with local partners who are demonstrating successful person centred and community based approaches, we developed a set of value statements that such systems can adopt.
In another publication, the PPL consultancy helped us develop economic modelling for person and community based approaches, such as peer support, education for self management, and health coaching. These provide a new kind of guide for commissioners and providers considering whether to invest in such approaches, and will be used in the MCP and PACS vanguards to create greater focus on community-engaged systems. We would urge everyone involved in developing financial and value-related strategies to take a closer look.
National Voices is a coalition of national health and social care charities working to bring service user voice into policy making in England.