Having set out the general case for moving away from the old fashioned idea that value in health care can only be found by buying more medical staff, kit or drugs, I have suggested that investment in patient health literacy would increase the value they contribute to their own care. This would, as a consequence, add value to the NHS as a whole and help change its resource base at this time of austerity.
But creating this value for the NHS, as with most value creation, actually costs some real money. I am certain that the value that patients could create for the NHS far outstrips the amount that would have to be spent to create it, but there is a concrete economic case that needs to be made.
And it is here in 2012, within the detail of the case for creating more value than it costs, that the co-production of value in health care needs to make its case.
Co-production of health care is a good thing for patients. It empowers them and gives them more influence over their health care.
Co-production of health care creates economic value in health care which will eliminate expensive costs that the NHS cannot afford.
It is this last point that needs the most attention now, in the summer of 2012. Over the last few years there have been several hundred offers made to the NHS promising to save it money. Very few of them have done so.
This is not to say that the economic hypothesis upon which they were based was necessarily wrong. Many of them indeed contained a strong economic promise that they could save money and were a good investment, but when applied on the ground they just seem to cost money rather than save it.
There are two reasons for this that the case for spending scarce resource developing patient value needs to avoid.
First the implementation of the new money-saving service did not have, as an integral part, a method through which the savings would be realised. So, for example, the NHS would buy a new cardio-vascular prevention service in the community – which would of course cost some money. The promise would be a reduction in spending on CVD services in the hospital as a result, but when the new community service was up and running no-one would actually save that money from the hospital.
So the NHS pays for the new but goes on paying for the old as well. In most other industries and services this is called ‘benefits realisation’ and is an integral part of any new intervention. The new knows that it needs to stop the old to realise the benefits – otherwise it cannot make an economic case.
In making the case for NHS investment in the development of patient-based value in health care by spending resources on patient’s capacity to better manage their conditions, we not only need to make the case for how this will save more money in other parts of the NHS, but we need to actually save that money. If that doesn’t happen, the creation of this new value does not increase the capacity of the whole NHS to get through difficult times.
This will call for a different kind of funding mechanism for the NHS. One that is now actually being developed through the year of care pilots. One where there will be clear financial incentives to keeping people out of expensive emergency beds by improving the secure management of their conditions in their homes. That is in hand, but it must be made to work.
The second reason why these interventions have not made their economic case is that they have only rarely been introduced into that segment of the health services where the economic case can be made most forcibly.
What do I mean by this? Many of the best examples of where new value has been created by patients have been at the point of diagnosis. People with long term conditions, say diabetes, when diagnosed go on one of the really good courses that have been developed by patient groups. They learn how to manage their new condition.
Nearly all of these courses increase the capacity of the patient to manage their condition and there is clear evidence that the patient’s vital signs are improved by the courses.
So they add value. But the problem is that for this group of patients, those that are newly diagnosed , the real costs that the NHS would otherwise have to pay out – the emergency bed stays in intensive care – are much less likely to have occurred in any case. It is almost certainly true that over 20 years this investment will have a big impact. But we need the value added and cost reduction to take place now.
That means that to make the economic case needed in 2012, the value added from patients’ capacity to better manage their own health care needs to come from those that are much sicker.
I was in Ontario a few weeks ago and there they had computed that 1% of the population consume 43% of the health care resource. The figures will be similar in England.
So to deal with the economic problem that the NHS has today, the value developed by patients to better manage their own condition needs to demonstrate its case not with those that are mildly sick, but those that are very sick.
This is a different proposition in so many ways. Most importantly the patients we are talking about are quite ill and will have been in and out of hospital for emergency beds on 3 or 4 occasions in the last year. They will have come to treat that sort of illness and life as if it were normal. If you are in and out of emergency beds you live your life at an understandably high level of anxiety and you don’t feel that you have very much capacity at all to invest in self management. It seems like an absurd possibility. Their condition is in charge of them, it seems impossible that they could be in charge of their condition
With such ill people what is there to build on? The answer to this is that in nearly every person there is a fervent wish that their lives were better. They want to be a bit more in charge of their condition rather than the condition being in charge of them.
One of the successes of the 1997-2001 government was the rough sleepers’ initiative where two thirds of rough sleepers stopped sleeping on the streets and moved into a variety of hostels. The people in charge of this initiative believed that inside people, who everyone else felt were without hope and capacity, there was an aspiration to live a better life together with the capacity to do little things to do it. Getting in touch with that capacity and aspiration is not at all easy and is usually met with a number of rebuffs.
But for hundreds of people who seemed without hope or resource, it was there. And of course it is these same people that are also very frequent and expensive users of health services. Their chaotic lives lead to very expensive use of health care – sometimes over 100 annual visits to A and E.
Increasing the capacity of people who live chaotic lives to manage their own health is an enormous prize both for themselves and for the NHS as a whole.
For investment in such capacity to demonstrate its economic worth, firstly the investment in the patient’s capacity to better manage their health care has to actually work. That is to say that the intervention really does have to create value for the person. They actually have to manage their health together with the NHS in a better way that adds more value to health care outcomes.
But the project also has to secure the savings that would otherwise have gone into expensive emergency beds. The money that would have been spent without the value that comes from the patient will really have to be saved.
In this way investment in a group of patients who would otherwise cost a lot of resource can demonstrate how it will save the NHS real resource.
I will return to this theme later using the example of how we have been able to increase the capacity of the frail elderly to manage by using the NHS in a different way from spending so many spells in emergency beds.