Value: the power of four

Across the developed world, healthcare systems have adopted the triple aim to deliver value-based healthcare – better health, better care at lower cost. Wales is one such system, but now it aims to take a step further by implementing a quadruple aim and putting a greater focus on the outcomes patients want.

The triple aim seeks to improve services by focusing on three dimensions of health and care:

• Developing population health and wellbeing
• Increasing the quality of services
• Producing high-value, lower cost health and social care.

The quadruple aim takes these three dimensions and adds the aim of developing a motivated, well-trained and sustainable workforce. The quadruple aim and the new focus on outcomes were outlined in A healthier Wales, a long-term plan for health and social care published at the beginning of the summer.

The new strategy is the government’s response to a Parliamentary review on the future of health and social care in Wales, carried out by a panel of health and care experts. Both call for a seamless health and care system underpinned by the quadruple aim.

Alan Brace, Welsh government health and social services group finance director, says services must now focus on implementation. Wales has taken a number of ground-breaking steps in recent years, he says, including legislation such as the Wellbeing of Future Generations Act.

This obliges public bodies to work together, focus on prevention and look to the long term.

Integrated university health boards – covering both planning and provision of care – and the moves the local NHS has made to integrate with social care have given the nation a framework that is right for the future, he adds.

‘We created a population health-focused organisational model in 2009, moving away from a market system, and organised ourselves around aspects of the triple aim.’

The new strategy, with its quadruple aim focus, addresses how the service will improve its population-based healthcare at the necessary scale and pace, he adds. ‘We have a good overarching framework for the future and the population health focus was right, as was the cross-public sector approach. The regional partnership boards bringing together health and social care was also right and a good foundation to build on. But, for me, the telling point made by the Parliamentary review was: if the case for change was so compelling, why hadn’t it compelled?

‘The review concluded this wasn’t a problem of strategy, policy or direction – the real issue was about execution. The review helped us focus on what needs to be done.’

Previously, all seven university health boards were required to develop plans to meet the needs of their populations. Different models were proposed, and Mr Brace says the centre is looking at measures that can be taken on an all-Wales basis and that can be done locally.

Changes will be supported by a £100m transformation fund over two years.

While Mr Brace insists this does not mean changes will be driven on a command and control basis, he adds that the central capacity and capability must be increased to support transformation.

‘We have to strengthen our approach to planning, performance management and delivery. Planning and monitoring have operated in silos in local government and health. But regional partnership boards are the vehicle for how we expect planning and delivery for health and social care to work in the future.

‘We are trying to build a foundation that people will be comfortable with, to plan and execute in an integrated way. There’s also some work here for me on how we allocate resources in a seamless way; how we plan our resources; and how we execute the transformation programme and target the transformation fund.’

He has been leading a commission looking at future spending requirements in social care. This is due to report early in the new year.

A study by the Health Foundation in 2016 led to more funding being allocated to healthcare. The same review suggested social care required an additional 4% a year.

Mr Brace is also developing a framework to allocate resources across the system, to support a seamless model of care with integrated pathways and pooled budgets. ‘We must think about how we measure and track resources in a different way, and infrastructure, capital and estates investment is linked to that.’ This work is due to be completed in 2019.

With its addition to the triple aim, workforce is a key element of the new plan. Like other parts of the UK, Wales has experienced issues with recruitment and retention. But as care shifts to new models, many of which are out-of-hospital, new skills will be needed.

The strategy says the government will invest in the skills needed in the future, including those required as technology advances, but it also commits to rethinking how staff can be used best. This includes team-working and using those best equipped to deliver the care needed.

‘Workforce is a real challenge for us and a real opportunity,’ Mr Brace says. ‘We talk about multidisciplinary working in health and social care, but our approach to training is still uni-professional. We need to think in a radically different way about the workforce of the future and start developing it now. We have set up a national body, Health Education and Improvement Wales, to bring all this together.’

As well as workforce development, research and development will be expanded, centring on innovation and improvement. Regional innovation and improvement hubs are being created.

Outcomes framework

A new outcomes framework and clinical plan will be produced as part of the strategy. In 2013, a Commonwealth Fund report comparing international healthcare systems ranked the UK first or second across its categories in all but healthy lifestyles (where the UK was 10th out of 11). However, in its 2017 report, the fund introduced a measure on outcomes and the UK came 10th (with the US 11th).

Mr Brace says: ‘This tells us we have created a system that is great at process and dealing with volume, is low cost and with access free at the point of delivery. But we haven’t created an effective system because when you introduce outcomes, you can see there’s a danger that we may be doing the wrong things more efficiently.

‘We have a technically efficient system where we manage inputs and outputs really well, but it is not allocatively efficient or effective.’

Allocative efficiency may sound more like economics than NHS finance, but it is becoming increasingly important as countries seek better care from the funding allocated.

‘We need to be more geared to effectiveness rather than efficiency and productivity. Clearly, it’s about measuring outcomes, but we need to think about the best outcomes we can deliver and how we allocate money in a more balanced way, rather than just making hospitals more efficient,’ Mr Brace says.

This does not mean an end to cost improvement plans and Lean programmes – the focus on technical efficiency will remain. ‘Two things must be on finance directors’ agendas,’ he says. ‘Every health system will still have to be technically efficient. The push on productivity and efficiency is not going away. But alongside that technical efficiency we need to be allocatively efficient. We must ask: “How do we allocate scarce people and financial resources? And how do we allocate to get the best outcomes?”.’

This could mean alternative care pathways. Some researchers have suggested that 30% of knee replacement surgery is unnecessary – a technically efficient system is concerned only with getting high volumes of patients through their procedures at lowest cost, regardless of outcomes. An allocatively efficient system would adjust the patient pathway according to the individual’s needs – avoiding surgery where appropriate.

‘We must ask where we need to be technically efficient and productive and where we should link to outcomes and the value-based agenda,’ Mr Brace says.

Rather than use outcome measures in silos such as the numerous clinical and technical outcomes, patient-reported outcome measures (PROMs) or patient-reported experience measures (PREMs) – which Mr Brace believes are too narrowly focused – Wales will continue to work with the International Consortium for Health Outcome Measurement (ICHOM) to pull all of this together. Its outcomes set allows internal and international comparisons, and Welsh health boards will look to learn from their counterparts in Sweden, for example.

Sweden was ranked second for outcomes in the latest Commonwealth Fund report and, while Mr Brace acknowledges some of this is because Sweden has a healthier population, he adds that it is also due to a more rounded approach to outcomes. While clinicians examine outcome data to improve their practice, they also bring in patient representatives to pinpoint improvements.

‘The culture is to look at outcomes in the round. Our approach will use internationally validated data to benchmark both outcomes and costs – that’s a key thing we are trying to achieve.’

As part of its transformation programme, NHS Wales is working with strategic partners to measure outcomes, using the ICHOM dataset. Measurement will be made before and after outcomes-based intervention that changes the patient pathway. ‘If there is no improvement, we will be prepared to ditch an intervention and then rethink it,’ says Mr Brace. ‘This will ensure we make the most of our innovation and transformation money this year and next year.’

Prevention of ill-health could reduce costs and is an important feature of the new strategy. ‘Everybody agrees prevention is the thing to concentrate on – if you can get that right, it will make a big difference. But seeing the benefits is hard when money is tight. We must ask: “How do we get serious about prevention? What is the business case for prevention and how do we get the prevention focus right?”,’ he says. ‘At a practical level, we may find that, as we go into some outcomes, it is better to invest in social care than health, for example.’

Value-based care also lends itself well to procurement of goods and supplies, he continues. NHS organisations tend to trade with suppliers over the long term, with the period punctuated by contracts being re-tendered and renewed and the focus on aggregating volume to drive down cost.

‘Suppliers or manufacturers often have expertise about optimising the use of their products within pathways to produce better outcomes. What if we contracted and reimbursed on outcomes achieved and delivered? That would change the risk/reward conversation hugely.

‘If 20 years ago somebody said to me that we would still be doing business with the same suppliers, by now we would have a different relationship. In short-term relationships, we are probably having the wrong conversation and some of the research on this found that suppliers have realised this as well.

‘I am keen to go down the route of value-based procurement. The conversation should be about added value. Most of the finance directors in Wales are also directors of procurement, so this is a big challenge for the finance profession here.’

Clinical engagement is a priority for all finance professionals in most healthcare systems and Mr Brace believes outcomes will help.

‘The typical clinician doesn’t go to work to implement system change or transformation. They go to work to improve outcomes for their patients. It’s an easier way to engage.’

He says the finance professional of the future should be well versed in value-based care. ‘Be a business partner and work with others to drive better outcomes for patients. It could also help us recruit more people to work in finance but requires different skills.’

Mr Brace says NHS Wales will move quickly to implement and evaluate the strategy to ensure it is not committed to a plan that has become obsolete.

Technology is driving rapid change in health and care, making long-term planning difficult, he says. ‘There is a notion that you can plan for 10 years and then do it, but most of the evidence shows that doesn’t work any more. Evidence shows you should do as much planning as you need, then execute the plan in the real world, with the flexibility to adapt, re-plan and redo.

‘Our strategy deliberately has a lot of front-ended tasks. We will implement quickly and then it’s about evaluation, learning and adapting,’ adds Mr Brace.

Clearly, the strategy seeks to create a seamless system with a focus on the outcomes patients want, but also one where change is evidence-based and, where necessary, continually evolving.

• The HFMA Wales annual conference will be held on 27-28 September. For more details, visit the branch page on the HFMA website