This week’s paper of the week is brought to you by Professor Sir Muir Gray, 3V’s Founding Director.
“If we are serious about improving quality of care and patient outcomes — whether mortality, readmissions, or patient centered [clinical] outcomes such as freedom from angina or heart failure symptoms — we have a responsibility to ensure that policies are grounded in evidence. We believe it’s imperative that before policies are implemented widely, rigorous studies be conducted to determine whether they achieve their goals. In addition to taking an evidence- first approach to policy implementation, we can better target policies toward specific diseases… As we move toward precision medicine and the delivery of diagnostic and therapeutic advances individualized to patients, we can also usher in an era of “precision policy” customized to specific disease processes.”
3VH commentary on the Implications for value improvement
Hitherto managerial measures introduced to improve healthcare have focused either on improving primary or secondary or tertiary care. Or on the various, and necessary, bureaucracies required to insure good governance of financial and human resources- health boards or hospitals or mental health trusts, for example. These initiatives have rarely been based on evidence and have rarely if ever worked as the levels of care or the institutions have turned the intervention to their own advantage. However, the authors are naïve to think that the same research standards for specific interventions can be applied to the complex domain of policy. So an approach to learning and testing is necessary, perhaps that outlined in Test, Learn Adapt by Goldacre, Togerson and the Cabinet Behavioural Insights Team.
 Goldacre B, T. D. (n.d.). Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials – GOV.UK. Retrieved March 26, 2019, from https://www.gov.uk/government/publications/test-learn-adapt-developing-public-policy-with-randomised-controlled-trials
The paper emphasizes not only the need for evaluation of policy initiatives before introduction but also the need to focus on “diseases processes’ in a “geographic area”. They call this precision policy ; we call it population healthcare, the third dimension of health care. 
The denominator is not the patients being treated by a hospital or by primary care, but all the people in need in a defined population. This requires evidence of cost effectiveness but even more important evidence of value.
It is fascinating to see how even the United States is having to face up to the reality of prioritization, optimising the management of finite resources, and how the NEJM, the bastion of high tech healthcare, is leading the way.
 Gray, M. (2017). Population healthcare: the third dimension. Journal of the Royal Society of Medicine, 110(2), 54–56. https://doi.org/10.1177/0141076817691024
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