Good outcomes? Bad outcomes? Let patients define value

‘The fundamental goal of healthcare is to increase value. We must define value as the outcomes that matter to patients divided by the cost of achieving those outcomes.’ This is the central thesis of Michael Porter, Harvard professor and business guru, which he presented at a lively conference hosted by the think tank Reform last week.

A relentless focus on value is the only way to achieve sustainable healthcare in a world of rising demand and highly constrained funds, argues Porter. We can’t do this by conventional ‘efficiency’ or obsessing about structures and organisations. The key lies in six mutually reinforcing components including integrated practice teams, much better measurement of outcomes and costs, and better IT. 

There is much to support in Porter’s ideas, which have already been influential. But I took issue with him on three questions at the conference: who defines value? Who creates value? Value to whom?

Measure the outcomes that matter to patients, says Porter. He is right. Yet he is oddly dismissive about patient experience. He acknowledges that we must measure experience but sees it as secondary, a proxy for ‘real results’ which he defines as ‘how the patient does functionally, quality of life, complications, recurrence of disease’.

This is not right. Healthcare is messy. Patients do not draw analytical distinctions between process and outcome; experience of care and the ‘results’. Ara Darzi was closer to the mark when he said experience was a fundamental dimension of quality. A bad birth experience is a bad outcome, even if mother and baby are physically unharmed. Being left to soil your sheets in a hospital bed is a bad outcome. A good death is a good outcome and, one might argue, the only outcome that matters for someone who is dying.

Outcomes that matter are the outcomes that the patient says matter. Let patients define value.

Now let’s look at who creates value. The Porter vision can come across as one where the professionals do all the value creating. Yet we know that informed, engaged patients make better choices; that people equipped to manage their own health conditions stay healthier and have a better quality of life; that confident patients are well placed to challenge poor practice at the point of care; and that having access to your own health record or your own personal budget can make you feel much more in control.

Almost every health conversation I join these days has a spell of handwringing about the health and care ‘workforce’: there aren’t enough, they’re too old, they’re in the wrong jobs etc. Ahem! Patients are a larger workforce than all the health professionals put together. We can not only define value but create value – if given the chance.

There is a bigger workforce still. Family carers, relatives, friends, neighbours and volunteers play an under-sung role in supporting and advocating for patients – helping them stay well, connected and out of hospital. Dementia friendly communities are based on the idea that many small acts of kindness and thoughtfulness can add up to something just as powerful – and a lot cheaper – than doctors, nurses and drugs.

The caring acts of families and neighbourhoods create value for patients. And cumulatively they create social value, helping to build healthier, more liveable and resilient communities. This silent workforce achieves much on a shoestring. The returns on quite modest investment could be very high.

Value is a powerful concept in health. Porter offers a compelling vision for creating value. It would be stronger for embracing the patient’s role in defining and creating value and for embracing social value. Is it worth taking a pop at Porter? Yes, because he is influential and because the gaps in his thinking are also the gaps that undermine much other thinking in health.

Jeremy is Chief Executive of National Voices, www.twitter.com/JeremyTaylorNV