The cultural shift towards a value-based approach to healthcare

Regardless of how we pay for them, healthcare systems globally are unsustainable in their current form due in large part to the growing burden of chronic disease, increased spend on new technologies and a workforce crisis. Neither are we equitably and reliably achieving the outcomes that matter, despite increased spending on health. Value-based healthcare (VBHC) is a useful lens through which to look at this problem and find potential longer term solutions. This is because we can interpret it as requiring attention to population health and reducing inequalities, supporting individuals in attaining their health goals and a focus on optimum utilisation of resources across whole pathways of care.¹

This in turn necessitates whole system redesign at a scale not attempted for many decades and is therefore a major challenge for health policy, healthcare organisations, professionals and patients. Value-based system redesign is as much about cultural shift and a change in mindset as it is about technical implementation of outcomes measurement or figuring out the best way to pay for services.

Change only happens when people are engaged. VBHC is a bottom-up activity that needs top down support, rather than the other way around. From an organisational perspective it requires deep collaboration between clinicians, financial managers, operational managers and informaticians, if it is to succeed in all the elements of system redesign. It is also necessary to drive forward in parallel the necessary policy changes at regional and national level to ensure that barriers to progress are removed. In short, every part of the system needs to be pulling in the same direction.

All of this change in healthcare is important but insufficient, because if people are to set their own health goals and achieve the outcomes that matter to them in their own context they need support and resources to do that. This is as much an intervention as any drug or surgery. Self-management does not happen by accident. Active participation in our healthcare means that we need to build health literacy in the population, provide information resources and coaching, plus access to our own healthcare record and information.

How did we effect cultural change towards a whole system, value-based approach in Wales?

This starts on the ground with multiple individual conversations, often over coffee, building a small movement of people with a belief. I have often joked that I bought a lot of cake in the early days of engagement and this is the truth. Later, this builds into informal seminars and talks to professional groups. This is never about imposing an ideology but much more about providing a set of concepts and tools to help clinical teams and organisations tackle existing problems. In parallel with this grass roots approach, securing buy-in from the executive team is vital to ensure that there is a minimum required level of support both strategically and in terms of resourcing to enable early projects to flourish and bear fruit. Later, engagement with health policy leads in government is also critical to enabling further momentum to build.

In Wales a national clinical lead post for VBHC was first created, subsequently growing a small team and program of work until it was possible to gain support for the establishment of the Welsh Value in Health Centre. Later, this enabled the foundation of the Intensive Learning Academy for Value-based Health and Care dedicated to formal education in VBHC. Healthcare providers in Wales now have VBHC teams, dedicated to supporting whole pathway design and patient‐reported outcome measures implementation. The heads of VBHC meet regularly through a national value delivery group to share learning and problem-solve together.

However, this major structural progress would never have occurred without that deep engagement early on and that persists to this day in grass roots webinars such as the monthly ‘healthcast’, broadcast on the last Friday of every month. This webinar is designed and chaired by front line clinicians, and takes topics and content from clinical teams across Wales and is part showcase, part debating chamber.

Healthcare is constantly evolving and engagement with colleagues never stops. VBHC is, after all, about collaboration not competition.

More information on strategy on Welsh Value in Health can be found on the website: Our Strategy – Value in Health (nhs.wales).