The NHS must learn from other countries

Value-based care orientates the concept of “value” to focus on the extent to which money spent achieves patient-relevant outcomes. That’s important because it’s well known that health professionals and patients don’t automatically have the same priorities.

The classic example is a doctor recommending a potentially effective treatment with significant side effects, while the patient’s priority is to feel as well as possible for her grandson’s wedding next month.

Making decisions together, with patient-relevant outcomes at the centre, helps make sure that each person’s management is right not just for medical reasons, but also for personal reasons.

According to a report published last month by the Economist Intelligence Unit, the more developed a health system, the more patients seem to value not just medical outcomes but also participation in decisions about their care.

Patient-reported outcome measures

Yet of the nine countries surveyed, which included countries like the US, Brazil, Germany and China, the UK was the only one to use patient-reported outcome measures in clinical settings – and even here, the number of procedures using PROMs has declined, and the number of clinicians acting on PROMs is unclear.

It is interesting that the UK scores highest in the report’s comparisons of health systems. Are we really better at value-based care than other countries? Patient-centred care has been a policy goal in the UK for more than two decades, yet our scores are still higher for strategy than for delivery.

Health services designed to fit around the needs of healthcare staff may struggle to achieve that. But systems that are designed to fit around patient needs may eventually be able to deliver it as a matter of course

We were, for instance, the only country to have guidelines recommending co-ordinated multidisciplinary team care for all of HIV/AIDS, epilepsy, psoriasis, osteoporosis and mental illness. However, according to the report, “Even the UK, which had the most consistently good results, has developed only islands of progress rather than system wide transformation.”

This is supported by a survey by National Voices referenced in the report that ”finds indications of movement towards patient-centred care” in specialties like oncology, but that this was less evident in more general care.

Many other countries have come to value-based care much more recently and have learned from the UK, such as Japan, which only recognised primary care as a board specialty in 2017. As these countries’ rate of progress increases, we must now look outwards to see what we can in turn learn from them.

After all, the ambition is not a simple one. For each of the nine countries included in the study, the shift from paternalism to partnership between health professionals and patients has required a culture change that is still a work in progress.

Perhaps the vital ingredient here is “co-created care”.

China’s health services have advanced in leaps and bounds, but patients were barely involved in the new developments.

Rather, health professionals and governments designed the systems they thought would work best for patients. The intention was to increase patient use of primary care, but according to this report, without engaging patients in the process, a lack of trust has persisted.

As a result, patients have voted with their feet, circumnavigating the primary care infrastructure to head directly to secondary care, keeping the system hospital-centric despite the health sector’s ambitions.

China’s chequered experience offers insight around the crucial role of patient involvement in achieving integration. No amount of health service funding, massive expansion of health coverage, or even primary care development has been able to achieve integrated care while health system planning does not engage patients.

At the other end of the spectrum, experience from other countries of involving patients in value-based care may be of interest.

In one US-based case, for instance, patients with health insurer Humana said they couldn’t afford transport to access health services, so transport costs were integrated into care; a substantial portion had food insecurity, so an assessment and measures to address that were also integrated into care. The insurer is currently assessing the impact on patient outcomes.

The UK’s weakest area was reported to be the delivery of care personalised to a person’s values and preferences – though few countries scored higher.

Health services designed to fit around the needs of healthcare staff may struggle to achieve that. But systems that are designed to fit around patient needs may eventually be able to deliver it as a matter of course.

There is no one-size-fits-all solution. But this report hammers home a lesson learned around the world: enabling patients to take part in their care can help turn a national ambition for patient-centred, joined-up care into a reality. Health authorities can omit this at their peril.