Much progress has been made in healthcare over the last 40 years, most of which has been achieved through technological advances in treatments, complemented by other approaches to increasing effectiveness:
Preventing disease, disability, dementia and frailty to reduce need
Improving outcome by providing cost-effective, evidence-based interventions
Improving outcome by increasing quality and safety of process
Increasing productivity by reducing cost
There are, however, three outstanding problems in every health service irrespective of structure or funding mechanism.
1. Unwarranted variation, in access, quality, safety, cost and outcomes.
In turn, the presence of unwarranted variation reveals the other two problems.
2. Underuse of high-value interventions
resulting in the failure to prevent the diseases and disability that healthcare can prevent
which may exacerbate inequity
which always results in waste, that is, any intervention that does not add value to the outcome for people in need or uses resources that could generate greater value if used for another group of people in need
which may result in harm, even when the quality of care is high
In addition, health services will have to cope with rising need and demand in a context where resources are unlikely to increase at the same rate as need and demand. To ensure the sustainability of healthcare we need to achieve greater value from the resources available.
In the USA, the meaning of the term ‘value’ is different: it is conceived as the relationship between outcomes for the patient treated and costs. In countries committed to universal health coverage this relationship would be termed ‘efficiency’ and it relates to technical value.
In health systems committed to universal coverage, value is a broader concept, encompassing ‘Triple Value’.
Personal value: improving the outcomes that matter to an individual for a given amount of resources* used not only by the health system but also by the individual and their family, recognising that the experience of care is a critical element
Population value: investing resources* more wisely within a health system to optimise the outcomes for the population for which the health system is responsible
Technical value: optimising the use of resources* to achieve the best possible outcomes for people being treated within a given pathway or process
* The term resources includes money, leadership time, staff time, assets, the carbon used etc.
More of the same, even if it is better quality, safer care, is not sustainable.
A new approach and set of activities are required to make healthcare sustainable:
a change in culture
training in new skills and concepts
the development of population-based systems