Systems under pressure
Health systems around the world face the twin pressures of a rising demand for services, coupled with financial pressure on resources to deliver them. For publicly-funded universal health services in developed countries such as the UK’s National Health Service (NHS), new investment is at an all-time low. Funding for the NHS in England has seen a real-terms rise of 4.4% over 6 years, meaning that the average annual rise was just 0.7% per year. Traditionally NHS funding had averaged at 4% per year.
At the same time in the developing world, pressure on frontline services is even more acute from challenges ranging from natural disaster, population displacement, communicable disease and often scarce availability of healthcare resources and skills to respond. Innovation is the best hope for policymakers and clinical leaders to meet and sustain the WHO’s Millennium Development Goals (MDGs) that aim to address the fundamental inequality in health outcomes between the developed and developing world.
Meeting the challenge with a value-based healthcare approach
In the face of these competing pressures on healthcare systems, Michael Porter of Harvard Business School argues that the time has come for a fundamental new strategy, which represents a shift away from the supply-side model of health care organisation towards a more patient-centred system focussing on achieving best outcomes at the lowest cost. It is termed the ‘value-based healthcare’ (VBH) agenda.
Central to delivering VBH is the Integrated Practice Unit (IPU). An IPU brings all related healthcare professionals together, organised around a given condition, in a multidisciplinary setting, having geographic reach and removing the need for the patient to travel around a variety of different services to access appropriate care interventions. The IPU team takes responsibility for the full cycle of care for the condition including inpatient, outpatient and rehab. It measures outcomes, costs and processes for each patient using a common information platform.
Using a common system of measurement
The International Consortium for Health Outcomes Measurement (ICHOM) is linked closely to VBH and seeks to provide a framework for measuring and reporting patient outcomes in a standardised way, making transformation of health care systems a real tangible possibility across different country settings.
Value-based health care in action
In the UK, local leaders of NHS acute providers in London, responding to a review of how the capital’s health services can be better organised to improve patient outcomes, re-structured their various stroke services previously provided through 30 acute hospitals into 8 specialist hyper-acute stroke centres (HASUs) based on the principles of the IPU in the value-based approach. Research led by UCL Partners suggests that through delivering HASU services by a centralised hub-and-spoke model, has led to significant reductions in both mortality and costs to the NHS, saving more than 400 lives since 2010. Further research has gone on to conclude that HASU services in London are saving more lives than would have survived under standard hospital treatment and have also reduced length of stay.
The small central African country of Rwanda is known as the land of a thousand hills, in part for its largely rural and agricultural terrain. There, healthcare leaders have used the principles of the value-based approach to improve its healthcare infrastructure and linked its outcomes to meet the MDG’s.
They have done so through the decentralisation of healthcare facilities to the community-level, improving accessibility of health care to local populations across rural terrain. This was complemented by the introduction of community-based health insurance scheme which is both affordable and comprehensive covering interventions ranging from bed nets to reduce incidence of Malaria to HIV/AIDS treatment. A performance-based financing model devised by the Rwandan Ministry of Health linking outcomes to payment has further cemented behaviour-change in the system to become a results-orientated healthcare provider. As a result Rwanda has made rapid strides in progress towards meeting the MDG’s.
Whilst these two countries, their populations, geography and health systems are considerably different, the common thread in their two examples is a willingness by local leadership to innovate and adopt aspects of the value-based approach to delivering healthcare. In these challenging times for policymakers and providers across a range of country settings, it may yet be the strategy that can best ‘fix’ healthcare.
Chris Bird is a PG student in IGHI’s Centre for Health Policy and a Project Manager in the System Engagement Programme at NICE.
 Appleby J. NHS Funding: past and future. The Kings Fund. 2014. Available at: https://www.kingsfund.org.uk/2014/10/nhs-funding-past-and-future (Accessed online 26 February 2017).
 Hunter R, Davie C, Rudd A, Thompson A, Walker H, Thomson N, Mountford J et al. Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model. 2013. PLoS ONE. 8(8)
 Morris S, Hunter R, Ramsay A, Boaden R, McKevitt C, Perry C et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. 2014. BMJ ;349:g4757
 The Economist Intelligence Unit. Partners in Health and Rwanda: Value-based collaboration. http://vbhcglobalassessment.eiu.com/partners-in-health-and-rwanda-value-based-collaboration/