How Should We Think About Value In Health And Care?
How should we thinkabout value in healthand care?Discussion paperSeptember 2015
About this paperThis paper is a step towards creating a new articulation of value inco-production with other stakeholders, in order to achieve the widerRealising the Value programme objective of demonstrating the valueof people and communities in their own health and care.The ideas set out in this paper will develop throughout the programmeto underpin future activities and outputs of the programme.Further information about Realising the Value can be found on the back ofthis paper and on the programme website: www.realisingthevalue.org.ukThis paper was produced by National Voices, reflecting the thinking and inputfrom the wider Realising the Value consortium.It is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike4.0 International License. We hope you find it useful.BHow should we think about value in health and care?
ContentsIntroduction12Our proposed articulation of ‘value’in health and care42Context for the value discussion63Approaches to thinking about value94Value in adult social care145Conclusions and next steps16Summary of the questions asked in this paper 18Bibliography and related readingHow should we think about value in health and care?191
Introduction‘Value’ is a contested notion both in the private and public sectors. Bothsectors’ definitions are – and have been over recent decades – subjectto significant tensions. Traditional ‘profit-oriented’ conceptions of valueexpressed through classical accounting models have been stronglycritiqued, yet continue to have a significant impact on the behaviours ofindividuals and organisations.In health care in England, perceptions of value have been dominated bya mix of clinical outcomes, system targets, competition mechanisms andencouragement for single units to act autonomously and be judged assingle services. What people using health services value most has not beenadequately considered or captured.However, a number of recent changes are raising the question of whetherthe current ways of thinking about value in health and care – clinicaloutcomes and service utilisation – remain sufficient. For example: Changing social attitudes have led to notions of wellbeing, quality oflife and happiness re-emerging in political conversation as values thatsociety aspires to for its citizens. This has also been recognised withinthe academic community with wellbeing measures being validated andput into use.The growing number of people living with long-term conditions ismaking it clear that patients are increasingly producers of their ownhealth care. This challenges the assumption of the traditional medicalmodel that the NHS produces value and patients consume it.The prevailing understanding of health is re-orienting itself from thequestion ‘what’s the matter with you?’ to the broader question ‘whatmatters to you?’ This begs the question of how the value that healthservices create sits alongside other forms of value.The long journey of adult social care towards personalisation haspointed the way to a values-based approach which prioritises improvedwellbeing, independence, social connectedness, choice and control; onein which people feel supported to manage their own care. The changedand changing nature of the ‘caseload’ of the NHS (long-term conditions,co- and multi-morbidities) would seem to point in the same direction. Thehealth and care systems are, in any case, increasingly aligning throughintegration programmes and will need aligned concepts and frameworksfor achieving and measuring value.2How should we think about value in health and care?
This paper suggests drawing on ideas from public and social valuetheory. Both lines of thought emphasise that the outcomes chosen mustbe securely based on ‘responsiveness’ to what relevant groups of people– ‘citizens’, ‘viewers’, ‘stakeholders’ – value, while balancing the needto measure and compare value. This is not a matter of simple opinionsurveys but of engagement with those constituencies to work throughtheir priorities (what some public value thinkers call ‘citizens’ refinedpreferences’). A similar ethic in social care and health is ‘co-production’.Experience from public and social value theory in other fields indicatesthat co-produced outcome measures will consist of a mixture of: quantitative evidence: for example, 5,000 people received theadditional learning resources they wanted; a social enterprise helped30 clients not to reoffendperson-reported outcomes: ‘I learned something from thisprogramme’; ‘I feel confident to return to work’qualitative judgements: commissioners taking an overall view ofhow a programme contributes to overall impact based on a widerdefinition of value.There are challenges to be addressed with such an approach. Qualitativejudgement, exercised by ‘value-seeking managers’, and the outcomesidentified by engaged stakeholders will both be programme-specific. Sothese co-produced outcomes may not be comparable across programmesand, as stand-alone measures, are vulnerable to a critique that they are‘subjective’ or used for self-justifying purposes.In real-world situations, co-produced outcomes will be confronted bythe legitimacy test identified within ideas of public value: that is, are theyconvincing enough to continue to secure legitimacy both with the publicwho value their services and with their elected politicians who determinelevels of resources? So another challenge is how to set up effectivemechanisms for legitimising what constitutes public value.*The question of how toassess value from a healtheconomics perspective,both in terms of methodsand outcome measures,will be a key component ofthis thinking as the workprogresses.This paper considers, therefore, how new frameworks and measures of thiswider conception of value can be created to assess financial, social andperson-reported outcomes. It sets out how we might establish a broaderway of understanding value and value for money in health and care. Aspart of the Realising the Value programme we want to debate these issuesin order to refine, redefine and develop the arguments in this paper.*Throughout this paper, there are a number of questions (summarisedon page 18). We welcome your views to help make concrete what anew framing of value in health care can look like. We will specificallyengage with the People and Communities Board of the NHS Five YearForward View (5YFV) to help us complete this work, and to champion theimportance of a new framing of value in the NHS of the future.It is in this context that we are testing the propositions set out in section 1 ofthis paper for a future, aligned articulation of value in health and social care.We look forward to receiving comments, views, challenges and suggestions.To feed back on the ideas and questions contained in this paper,please contact the Realising the Value consortium partners oninfo@realisingthevalue.org.ukHow should we think about value in health and care?3
1Our proposedarticulation of ‘value’in health and careQuestions Are the propositions set out in section 1 the right ones to develop? Are there any further implications from these propositions thatyou would like to draw our attention to? Do you have suggestions for approaches to thinking about valuethat capture some or all of these propositions (in addition tothose referenced in section 3 of this paper)? What challenges do you foresee – and how can they be overcome?We propose that a future, aligned articulation of value in health andsocial care will need to take account of and be supported by thefollowing features:4 Co-produced outcomes: The articulation should favour andincentivise outcomes that are ‘co-produced’. This means servicesshould enable service users and other stakeholders to identifydesirable outcomes to be planned for, and collaborate with themand others to achieve those outcomes. Diverse outcomes: It should be capable of combining a core ofquantifiable and comparable outcomes with others that cannot beaggregated; accepting as legitimate a wider ‘narrative’ for valuethan, for example, clinical effectiveness or meeting service targetsand objectives. Clinical and personal health outcomes will need anew place within this redesigned core of outcomes. They may alsoneed defining more holistically through focusing on the outcomesfor the person rather than, or in addition to, the success of atreatment or intervention. Impact from people, communities and services: This newarticulation of value should lead to an approach that emphasises overall‘impacts’ achieved by people, communities and services combined. Longer-term and person-centred impact: The impacts identifiedin this approach are likely to be longer-term and more driven by whatis important to the person – for example, wellbeing, independence,social capital, feeling confident and supported to manage their life,health and care.How should we think about value in health and care?
Localisation: This articulation of value will require a decision-makingenvironment that enables creative and adaptive management andcommissioning at the local level. For example, allowing localisedjudgement on the achievement of the non-comparable outcomes. New measures of value: National policymakers will need new andupdated measures to support this articulation of value. These shouldincorporate a broader range of tools and measures for wellbeing,quality of life and personal outcomes, which are combined into robust,common evaluation frameworks for health and care interventions. Measuring what matters to people: such measures must be capableof capturing a ‘full range’ of valued outcomes of services andprogrammes, with due emphasis on the outcomes most valued bypeople using services.In the remainder of this paper we outline how the arguments to supportthese propositions were developed, and ask further questions for feedback.How should we think about value in health and care?5
2Context for thevalue discussionQuestions Are there key concepts of individual and community value wehave not referenced in section 2? Do you know of any significant programmes or services in theNHS that have attempted to account for these types of valueover time? Please send us references/details.A consensus has been reached that the NHS needs to move away frombeing a reactive, episodic service, based on a medical model of ‘diagnose,treat and cure’.Core ‘customers’ of the NHS are now people with long-term conditions,including mental health problems and, increasingly, people with multiplelong-term conditions (‘multi-morbidities’). These groups account forthe consumption of the majority of NHS ‘inputs’, including funding,consultation time, medication and hospital admissions. Securing greatervalue for the future NHS is, to a large degree, contingent on better –and different – models of care, support and treatment for these groups,including at the end of life.There are strong parallels and overlaps with the adult social care caseloadof people with increasingly complex needs such as disabilities and frailty.Increasingly the expectation is that the NHS and social care serviceswill jointly plan, commission and provide services and support peopleto manage these complex cases and needs. This will require commonconceptions of value and aligned mechanisms to account for it.Evidence has been building over the last two decades about the benefitsof both person-centred (or personalised) interventions and the value of thecontributions that individuals and the community and voluntary sectorscan make to supporting people’s health and wellbeing. However, in thehealth service these approaches have not yet become part of mainstreamways of working.The 5YFV, in addressing the future of health and care, calls for new waysof working with people and communities and the use of person-focusedinterventions as an integral part of new models of care.6How should we think about value in health and care?
This raises the need for a new, cross-system, common understanding of‘value’. What is the value to society that the provision of treatment, careand support should seek to deliver? How can that concept of value beadapted and developed to include, at its core, the value that citizens andcommunities most seek to achieve? Moreover, how can it also recogniseand mobilise the value that people and communities can themselvesdeliver? Where can we look for evidence and clues to this, and how canwe begin to frame a new model of value that can assist our public servicesto reshape themselves for 21st century challenges?The value contributed by individualsand communitiesThe 5YFV is a significant landmark in its recognition that value iscontributed by individuals and communities and that value can bemultiplied where public services work in support of them. However, it isnot the first to do so, and it builds on the following key milestones: theWanless Review (2002); Department of Health research on individualengagement (2004); Angela Coulter’s Health Foundation review ofpatient-focused interventions (2007); NICE guidance on communityengagement (2008); NHS England’s participation guidance (2013); NationalVoices’ evidence review (2014); and Jane South’s report on communitydevelopment for Public Health England (2015). These reports and othershave accrued evidence of the value of engagement over a long period. SeeBibliography and related reading at the end of this paper for more details.There is a growing body of indicators which estimate the economic valueof contributions made by a variety of different groups, including:*This evidence base isbeing assessed as part ofthe Realising the Valueprogramme and a report ofthe findings will be publishedin the autumn of 2015.How should we think about value in health and care? Volunteers: the value of voluntary activity in the UK has beenestimated by the Office for National Statistics (ONS) to be 23.9bn(ONS, 20
In health care in England, perceptions of value have been dominated by a mix of clinical outcomes, system targets, competition mechanisms and encouragement for single units to act autonomously and be judged as single services. What people using health services value most has not been adequately considered or captured. However, a number of recent changes are raising the question of whether the .
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