Written evidence from Better Value Healthcare
(COM 34)
Why is it we know to the nearest £ what we
spent in every health centre and hospital and not to the nearest
hundred million what we spend on bi-polar disorder or rheumatoid
arthritis?
Why is that even we know we know we spend about
£1 Billion on asthma we do not know what value is derived
or what value could be derived from £900 Million expenditure?
THE ETERNAL
VERITIES OF
HEALTHCARE
This is my 22nd reorganisation but few have
made much significant difference. Furthermore rheumatoid arthritis
existed before the first of my organisations and exists now. Over
the last 30 years I have seen some developments in Programme Budgeting
and Systems, for examples in cancer, renal services and stroke
but some of these have been determined by the need for capital
investment. Most of the Health Service still resembles a Brownian
Motion namely the random movement of patients, clinicians, blood
samples and reports.
THE NEED
TO FOCUS
ON VALUE
What is needed is firstly to appreciate that
value is the most important criteria not quality. Obviously quality
improvement increases value but to maximise value it is necessary
not only to do things right but to do the right things. The value
derived from Health Service is measured by the relationship between
cost and outcome.
THE NEED
FOR PLANNING,
PROGRAMMING AND
BUDGETING
PBB was introduced in the US Defence Department
in the 1960's. Instead of continuing to fund separate requisitions
from Army, Navy and Air Force Robert S McNamara introduced the
concept of Programme Budgeting, how all the Military Services
had to work together.
The United Kingdom is fortunate in that we have
the best Programme Budgeting information in the world set out
in Table 1 below:
Table 1
| Estimated England level gross expenditure by Programme Budget
| 2008-09 |
| | £000s
|
| 1 | Infectious Diseases |
1,410,980 |
| 2 | Cancers and Tumours |
5,134,948 |
| 3 | Disorders of Blood |
1,253,786 |
| 4 | Endocrine, Nutritional and Metabolic
| 2,526,152 |
| 5 | Mental Health Disorders
| 10,415,840 |
| 6 | Problems of Learning Disability
| 2,916,182 |
| 7 | Neurological | 3,683,873
|
| 8 | Problems of Vision |
1,664,102 |
| 9 | Problems of Hearing |
417,167 |
| 10 | Problems of Circulation
| 7,420,201 |
| 11 | Problems of the Respiratory System
| 4,247,325 |
| 12 | Dental Problems | 3,087,416
|
| 13 | Problems of Gastro Intestinal System
| 4,097,920 |
| 14 | Problems of the Skin |
1,794,226 |
| 15 | Problems of Musculo Skeletal System
| 4,212,469 |
| 16 | Problems due to Trauma and Injuries
| 3,299,792 |
| 17 | Problems of Genito Urinary System
| 4,000,641 |
| 18 | Maternity and Reproductive Health
| 3,100,821 |
| 19 | Conditions of Neonates
| 1,101,470 |
| 20 | Adverse effects and poisoning
| 955,442 |
| 21 | Healthy Individuals |
1,908,832 |
| 22 | Social Care Needs |
3,156,039 |
| 23 | Other | 24,836,323
|
| Total Gross Expenditure |
96,814,987 |
The first step is to review the allocation by programme both
nationally and by commissioner. To help this every Primary Care
Trust in England was sent a Health Investment Pack in September
2010. However before switching resources from one programme budget
to another it is far more important to engage clinicians with
patients and debating the use of the resources they already have.
WITHIN PROGRAMME
AND WITHIN
SYSTEMS ANALYSIS
The Health Service of the 21st Century should be run not
on the basis of Institutions, which will continue to be necessary,
but on the basis of Systems, Networks and Pathways and the definition
of these terms given below.
A SYSTEM is a set of activities with a common set of objectives
(also known as a service).
A NETWORK is a set of individuals and organisations that
deliver the system's objectives (a team is a set of individuals
or departments within one organisation).
A PATHWAY is the route patients usually follow through the
network.
A PROGRAMME is a set of systems with a common knowledge base
and a common budget.
Thus when looking for increased investment in the management
of chronic obstructive pulmonary disease, for example, the first
place to look is within the lung disease programme budget and
within that in the systems budget for chronic obstructive pulmonary
disease.
The development of this approach will engage clinical and
patient organisations. Before campaigning for more resources for
their particular priority such communities of interest need to
look within their whole programme budget to see if the innovation
could be funded by reducing waste. This is what commissioners
should require them to buy commissioning programmes and systems,
not primary and secondary care.
October 2010
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