Value and values

When approached to be editor of this special edition of FHJ on ‘values’, I was enthusiastic but a tiny bit anxious. The importance of including concepts of ‘value’ in healthcare has become widely accepted, but how do we define ‘value’? What does it actually mean? The term ‘value-based healthcare’ appears to have been coined by Prof Michael Porter, of Harvard University, who argued for redesigning systems around outcomes that are of ‘value to patients’ and the costs to achieve those outcomes.¹ In the American system, this has come to mean payments to physicians for attaining agreed patient-related outcomes and is a riposte to fee-for-service and capitated models of reimbursement, both of which are based around how much healthcare is provided.² As the NHS delivers healthcare free at the point of service, it has been argued that value-based care in the British context should consider how the national budget can be used to promote better outcomes at population level.³ Still others advocate that both doctors and patients, as individuals, should determine their own ‘values’, with a negotiation as to what the appropriate goals of the therapeutic relationship should be.⁴

Such a plethora of meanings seemed difficult to contain with a single issue of a journal. What if the authors took such diverse stances on ‘value’ and its role in the delivery of care that we were left with a ‘Humpty Dumpty’ scenario, where the word was stripped of any shared understanding?

We are fortunate, instead, to have a series of articles that not only explore the nuances of the word ‘value’ but also how this might be applied across nearly all aspects of health and care. At the macro-level, Sally Lewis discusses the strengths and limitations of value-based healthcare and whether it might provide a meaningful solution to the problems currently faced by the NHS, while Matilda Allen, Dominique Allwood and Sir Michael Marmot propose reframing our conception of hospitals to places that create value beyond the provision of direct clinical care.^5,6 Lorelei Jones explores how different healthcare paradigms demand different frameworks for management and considers the need for incorporating notions of ‘value’ into the governance of integrated care systems.⁷ How industry contributes to creating and supporting values-based care is discussed by Frédéric Noël.⁸

Different dimensions of ‘value’ as they relate to patients are explored in two articles. Jennifer Schulz discusses how the concept of ‘value’ to patients and their families after medical injuries has played a role in reforming the legal framework for medical negligence in other jurisdictions and ponders whether a similar change might be good for Britain.⁹ Rosemary Hollick and Lynn Laidlaw explore the value in patient and public engagement in research and how it can help to move patient and public involvement away from being ‘tokenistic’ towards being an integral part of the process.¹⁰

Values and how they play a role in decision making on the acute medical unit are discussed by Luke Martin, while Andrew McLaren, Louise Locock and Zoë Skea explore what doctors value in their own personal and professional lives when it comes to making decisions about where to live and work.^11,12

Three themes recur in these very different papers. Firstly, that concepts of value are inherent within medicine and, indeed, underpin it. The shift to value-based medicine is then not so much a radically different system, but rather a way of surfacing what is already there and bringing this to the forefront of our working lives. The second is the necessity of creating and negotiating shared values between doctors and patients and across all the different components and stakeholders within a system. The final point is that despite the barriers to value-based care, it has the promise to be truly revolutionary. Beyond the obvious benefits of more efficient and effective patient-oriented care, it might just be the antidote to the burnout and exhaustion experienced by a workforce that is currently stretched like never before. It might be a pathway back to joy and satisfaction in the working lives of doctors and other medical professionals.

In the end, I ought not to have been worried; this was the easiest editorial task I have ever been assigned. This was no doubt in part to my co-editor, Suzie Bailey, whose enthusiasm was infectious. But also because this is the first time every author met every deadline and we actually had people volunteering to make contributions. This demonstrates the appetite for a bigger conversation about values.

We hope that this collection of articles has stretched the boundaries about what value-based care might mean for the NHS and other healthcare systems across the world. It has certainly stimulated me to think. We hope it does the same for individual doctors, managers and leaders as well.