The clinical advances of the last fifty years have led to dramatic increases in life expectancy and years of life free from diseases and other health problems. However, even after two decades of evidence based decision making, guideline production and explicit focus on quality and safety every country on earth still faces still five outstanding healthcare problems:
The first is massive unknown and unwarranted variation, with unwarranted variation being defined by Jack Wennberg as “variation in utilization of healthcare services that cannot be explained by variation in patient illness or patient preferences”. These variations reveal four other problems that can be observed:
- patient harm, from over diagnosis and over treatment, even when the quality is high
- inequity, from underuse of high value healthcare services by certain social groups
- waste in healthcare, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients
- failure to prevent the diseases that healthcare can prevent stroke in atrial fibrillation for example.
In addition, every healthcare service faces the new challenges of rising need and demand, which in most countries will increase faster than the healthcare resources available.
These problems will not be solved by:
- the injection of more money, in part because there is no more money, in part because they have developed and persisted in an era of growth in investment that will never be repeated.
- medical technology. Some new technology will mitigate them but other technology will aggravate them.
- structural reorganization. Bureaucracies are necessary but not sufficient.
To cope with these problems we need a new solution: Value Based Healthcare, which requires four new types of interventions: