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Value-based Healthcare - a medical student's perspective

Value-based Healthcare - a medical student's perspective

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by Arwel Poacher, Medical student at Cardiff University
June 2019
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Having just completed my medical school finals, I’ve spent the last years learning the basics of what it means to be a healthcare professional in today’s national health service. I have come of age, so to speak, in possibly one of the most volatile periods of change medicine has seen – the ‘technological revolution’.

Technology has had, and will continue to have, an immense impact on medicine, with recent examples being robotic surgery and the digitisation of health records. But, how can we as a profession capture the opportunities of these technological innovations, and ensure they improve the quality, or value, of our healthcare? From my short time at Concentric so far this appears to be a core philosophy of this ambitious team.

Undergraduate curriculum

This move towards a patient-focused approach to healthcare, and healthcare innovation, is one directly reflected in the undergraduate curriculum. Undergraduate medical training has shifted away from instilling a traditional, paternalistic model of doctoring. Rather, we’re taught from the outset to consider and empower the individual. It’s clear my generation of doctors are keen to support and drive improvements to an increasingly complicated system. I see a focus on patient-centred care being the compass to guide and prioritise such improvements. Hopefully many share my enthusiasm that there is an opportunity to use technology to improve the value of care, rather than simply technology for technology’s sake.

Value-based healthcare

Firstly, we set our definition of value in healthcare. We can use Harvard Business School Professor, Michael Porter’s definition of value being outcome over cost. Seems a sensible definition. However, as I delve deeper the water becomes a little murkier… Professor Porter is well quoted in referring to medicine as a ‘fact-free zone’ - do we really know what outcomes our healthcare delivers? Do we even really know how much care, at an individual level, costs?

Beyond apprenticeship-style clinical decisions, rigorous research output - randomised controlled trials and the like - presented in scientific literature have often directed clinical guidance set out by entities such as NICE. However, there are a number of issues with applying the outcomes of such studies to real-life practice. Often, large proportions of ‘real-life’ patients - patients that will be the recipients of treatments - are excluded from trials due to comorbidities etc. And potentially more importantly, studies have rarely assessed outcomes that are important to patients, reported by patients.

Outcomes that matter

But why have the measured outcomes not always been aligned with those that are important to patients? Traditionally, as well as it simply not being the culture of research, it’s been considered hard to define what is important to patients – it changes so drastically on an individual basis – and the profession has tended to rely on the intuition of doctors. It stands to reason that medical professionals develop a sixth sense of best interest, but I’m interested to know how well this relates to what really matters to individuals, as well as how well we understand what our patients’ outcomes are from their perspective.

With a lack of understanding of the outcomes that matter, it seems likely that we are missing opportunities to improve the value of provided healthcare. There seems to be a number of changes coinciding which is leading us to unlocking this potential. Firstly, with increasing connectivity across all age groups and increasingly connected health records it is simpler to collect outcome data. Secondly, there is an increasing realisation in postgraduate medical communities of the value of the patient voice (both at an individual level and for designing systems). Lastly, the clear shift towards holistic patient-centred approaches at an undergraduate level means that the value-based agenda feels familiar to what we know.

‘Business as usual’

At Concentric we’re interested in using outcome measures to directly support patients and clinicians making decisions around what matters to an individual. Taking inspiration from, and building upon, work by the International Consortium for Health Outcomes Measurement (ICHOM), which is leading work regarding the identification and measurement of outcomes that patients deem important. During my internship with Concentric I aim to understand how patient reported outcome measures (PROMs) can be best applied, directly at the point of care, to positively influence and support shared decisions across the surgical specialties. As described by Dr Sally Lewis in a recent BMJ opinion piece, Patient reported outcome measures enhance communication with patients, when the purpose of measuring outcomes is opaque it leads to difficulties. She describes that the “primary use of patient-reported outcomes should be to enhance the communication between a patient and healthcare professional with the aim of a better shared understanding of context and goals leading to shared decision-making.”

I came to Concentric with a very limited understanding of value-based healthcare, a position I suspect I shared with many students and junior medical professionals. Having never really considered in detail, my impression had been that outcomes and costs were easily quantifiable and known. Initial explorations into the field of value-based healthcare reveals hidden complexity, and lots of opportunities…

“The very act of considering the questions in a PROM began to affect the balance of power in the consultation, giving the patient a tool to lead.”

- Dr Sally Lewis, National Clinical Lead for Value-based Healthcare in Wales