Toward an Outcomes-Based Health Care System: Title and subTitle BreakA View From the United Kingdom

The core purpose of a health system should be to maximize the health of the population. When the main challenge is managing long-term conditions, maintaining health rather than delivering health care per se should be the goal.

In a comprehensive, publicly funded system like the United Kingdom's National Health Service (NHS) there is an overriding imperative to deliver maximum health benefit per pound spent. Quality, effectiveness, and efficiency are the goals. Traditionally, physicians and other health care professionals have regarded financial efficiency as outside the scope of their professionalism (indeed, often at odds with it). The concept of value—useful health outputs divided by the resources needed to achieve them—as advocated by Porter and Teisberg¹ and others is relatively new and unfamiliar to many clinicians. However, the need to achieve more with less puts the need to strive for value into sharp focus. Following a decade of above-inflation increases in NHS funding, the urgent need to reduce the United Kingdom's national debt means the NHS is entering a sustained period of flat or declining funding, while demand for services continues to increase (from technological progress, an aging population, increasing expectations, and population growth). Striving for value therefore becomes an ethical imperative.²

However, to make progress on value requires being clear about what the numerator of the value equation should describe. This must be quality of care as expressed by useful health outcomes, relevant to patients. Although the principle of measuring and reporting quality is now widely accepted,³ what should be measured to drive maximum improvement in quality is far from clear. The new coalition government has a system reform agenda for the NHS in England that is focused on outcomes.⁴ These reforms must correct some serious shortcomings in the NHS's current approach to measuring quality, in particular:

Many health care institutions and clinicians object that their business only encompasses a small section of the whole pathway. Although this is true, it is also precisely why a more holistic way of measuring quality is needed. A high-value health system not only deals effectively and efficiently with acute stroke, but also reduces the incidence of stroke (through risk stratification, targeted management, patient education, and primary care) and is also concerned with rehabilitation and secondary prevention. Focusing on the acute phase risks optimizing 1 part of a continuum, and missing the opportunity for prevention, which can obviate the need for expensive “rescue” care. By contrast, a whole-pathway quality measurement approach, focused on relevant outcomes, will promote working arrangements (and payment systems) better aligned with the core purpose of the health system—health, not health care.

Long-term conditions provide a particular opportunity to maximize value over time for individual patients and for the health system, since these patients experience greatest morbidity and incur the highest costs. For these patients, value is determined by summing a triad of clinical outcomes, patient-reported outcomes, and patient experience, and dividing this by the cost of care over a 1-year period. The whole-pathway approach helps focus care on maintaining health and maximizing functional status over 1 year in the patient's life.

How should whole-pathway measures be developed? One solution is to bring together patients, families, and health professionals with an end-to-end view of the pathway and to use their combined expertise to define the elements of the pathway and the small set of outcome measures that best describe success along the whole pathway.

Over the next 20 years, improving the organization of health care will have more effects on health status than new drug or technology discoveries. The potential to drive step changes in results through better organization of care (by systematically linking reliable processes to techniques of change-management) is now well described.⁷ However, better organization of care in particular communities is a further frontier—demanding a multidisciplinary approach of a different order not only across all specialties of health care professionals, but going beyond biomedicine to include disciplines as diverse as anthropology, sociology, and engineering.

An era of increasing financial constraint paired with greater emphasis and transparency on quality should drive a value-centered approach. To benefit patients and populations, it is imperative that the quality numerator of the value equation measures those outcomes that are most relevant to patients across whole pathways. Academic health science systems are well placed to drive such an approach.⁸