Focusing on value rather than quality means fewer resources are wasted on pointless tests or policies that have no meaningful effect, writes Sir Muir Gray

Woman looking through microscope

Laboratories have exceptionally high standards, but the tests they provide can be of low value when clinicians use them incorrectly or have no suitable reason to ask for the work to be carried out.

Lab tests

Quality has dominated the debate for the past 10 years, but the paradigm in healthcare has now shifted to focus on value. Some people find the relationship between the two confusing. 

‘A test can be of high quality but negative value if it leads to the patient receiving unnecessary and risky interventions’

Surely, they argue, high quality care must be of high value. But this is not necessarily the case. High quality care increases the probability that there will be the intended outcome, but value is attached to the outcome, not the quality.

If high quality care produces a poor outcome or an outcome of low or even negative value, then the service is of low value.  

Unnecessary risk

Let us take a simple example. The x-ray computed tomography scans given to a group of patients might all be of perfectly high quality, but some scans could have been ordered by junior doctors simply because they were nervous of what their seniors would say if they had not done so. Therefore the results made no difference to the patients’ outcomes or care, so they are of low value.

‘There comes a point when the investment of additional resources to improve quality does not result in value for the population’

If the scan coincidentally identified a tumour that had presented no symptoms and would otherwise have gone undetected, then the outcome could do more harm than good, by requiring an unnecessary operation, for example.

Laboratories are often excellent examples of organisations that have very high standards and rigorous external quality assurance mechanisms, but many laboratory tests have low value. That’s not the fault of the laboratory, but the fault of the clinician who has ordered a test because they could not think of what else to do.

Furthermore, a test can be of high quality but negative value if it produces a positive result that leads to the patient receiving unnecessary and risky interventions.

Zero value policy

Quality improvement and safety improvement interventions also have their own value − and it’s not always high. If a service is of very low quality then measures introduced to improve the quality will, by leading to a better outcome, have an impact on value.

However, there comes a point when the investment of additional resources to improve quality, or even to improve safety, does not result in value for the population served.

There comes a limit beyond which further investment in quality or safety improvement does not add significant value or even any value.  For example, in England, it was decided that all podiatric nail clippers should be thrown away after a single episode of use because they might transmit Prion disease. The probability that they would do so was infinitesimally small, but that was the safety policy.

What value resulted from throwing away 10 million nail clippers a year − vividly called the “nail clipper mountain”? None that could be measured. This is an example of safety improvement intervention that had zero value.

Sir Muir Gray is director of Better Value Health Care