Now that the dust has settled somewhat on the furore surrounding the Health Bill, I find myself thinking about the domestic and truly international health agenda.
Starting with the home front – how do we get medics to consider the concept of value in healthcare? It would seem that we know little of how value is applied and understand less.
The last 50 years have seen a revolution in the care of people with cancer. Good research, better education of clinicians and the investment of large amounts of money have improved survival in most cancers and cured a proportion. The paradigm has shifted from effectiveness to cost-effectiveness and in the most recent decade to quality. But perhaps for decades to come, the focus of those who pay for or manage healthcare, most of whom are clinicians, should be value, as defined by Michael Porter last year in the New England Journal of Medicine:
“Since value depends on results, not inputs, value in healthcare is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs. Since value is defined as outcomes relative to costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false ‘savings’ and potentially limiting effective care.”
It will be a huge challenge to the NHS Commissioning Board. Let the board invest where it considers it appropriate and disinvest in low value interventions so that it generates its own capacity to respond to novel, effective therapeutic innovations.
On the international front, I was delighted to be invited to a recent interactive hearing conducted by the United Nations to inform a paper which it will present to heads of state at a high level meeting on chronic diseases in September. A wide range of representatives from non-governmental organisations, civil society, the private sector and academia were at the hearing, which had three linked sessions.
First, the scale of the challenge. Non-communicable diseases are the leading cause of deaths globally and are increasing. In 2008, 36.1 million people died from heart disease, stroke, chronic lung diseases, cancer and diabetes. Almost 80 per cent of these deaths occurred in low and middle income countries. Each year, there are 9.1 million deaths from these diseases in people aged under 60. In Europe, it has been estimated they cause around 85 per cent of annual deaths.
Second, national responses to the challenge of these diseases. This provided a series of concrete and proven interventions, which individual states could implement for prevention. These included tobacco taxation, smoking bans, reducing salt in food, reducing alcohol use and stopping the inappropriate marketing of unhealthy food to children.
Third: what is needed to enhance international cooperation? International responses to this enormous challenge to the world’s health are fragmented, lacking focus and coordination. This is an area in which the World Health Organization and a few key member states could play a role, and there is no doubt that the UK’s commitment to strengthen primary healthcare systems in the developing world will make a significant impact.
As the president of the European Society of Medical Oncology I have formed an alliance with the European societies of cardiology, diabetes and respiratory diseases, collectively representing more than 100,000 health professionals, to provide a single voice that carries further in the corridors of power than if we were to act as individual organisations. I have been most struck by the commonality of risk factors that this disease grouping shares and how unusual it is for us to work together across the specialties.
A programmatic approach to chronic disease services may be one way of finding the integration mandated by the reformed bill.