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When you begin a book with the words ‘Oh fuck!’, you'd better make it worth reading. When you begin a book about health care with those words and you happen to be a guru of evidence-based health care, you'd better make it essential reading or have lots of friends.friends.
The release of last month's report by Derek Wanless, commissioned by the King's Fund, might mislead some observers into believing that the value of health care is a matter of recent concern. Wanless argues that increased funding of the NHS has produced better paid doctors, more obesity, and little in the way of better productivity when we consider clinical outcomes.
Debates about the value of health care are, of course, as old as health care itself. In recent times they have been heavily influenced by the random but incisive reflections of Archie Cochrane, the reluctant but pioneering analyses of Armenian Avedis Donabedian, and the succinct but piercing observations of John Muir Gray.
Money is at the heart of these considerations. No health service can afford to pay for all possible treatments. Increasing affluence brings greater demands for better health and health care. Better informed patients, an ageing population, new diseases, modern lifestyles and technological advances have placed unbearable costs on health systems.
But money alone is not the answer. The Law of Diminishing Benefit informs us that there comes a point when increased resource fails to deliver further health benefits, while the Law of Undiminished Harm describes how harm continues to increase despite greater resource. When these two effects are considered together it is possible to predict the health gain—the difference between benefit and harm at any level of resource. If plotted on a graph, the curve of health gain is a hump: the amount of resource that delivers the maximum health gain is the crown of the hump and is also the point at which value is at a maximum.
Value, though, means different things to different people. Payers, patients, clinicians, managers and industry all have their own perspective. There are dictionary definitions of value and numerical definitions of value. As well as attempting to understand and reconcile these differences, Muir Gray has created a series of single-page aides-memoire to help managers and payers achieve better value health care.
One failure of health care is the burden of information on health professionals. As befitting the man who coined the ‘Information Paradox,’ Muir Gray keeps his words few and well chosen. The complex thinking that helps determine value in health care is compressed into less than a hundred short, simple pages. For time-strapped professionals without the patience for even these few words, or those with a hunger for more, there is an associated radio station (http://www.soundshealthy.org), where Muir Gray draws you further into his world of better-value health care. It is also a world that resonates to the sound of Freddie Mercury singing Radio Ga Ga. The words ‘Oh fuck!’ spring to mind...