Value-Based Health Care in a time of COVID

Interview: Dr. Sally Lewis, National Clinical Lead for Value-Based and Prudent Healthcare, explores how the pandemic could be the catalyst for a new era of care

Background
The COVID-19 pandemic has added pressure to a stressed system, generating new demand and prompting a rethink of how services are delivered. Dr Lewis says that by focusing on patient outcomes and embracing proven telehealth technologies, Value-Based Health Care offers a route towards new and more sustainable models of care.

What is Value-Based Health Care (VBHC) and why is it now in the spotlight?

The main premise is to achieve the best health outcomes we can for the Welsh population with the resources we have. We have been applying this approach in several therapeutic areas in recent years. Our VBHC team has worked with clinical teams and patients to collect Patient Reported Outcome Measures (PROMs) in clinics or remotely on mobile devices.

How has this approach been applied in response to COVID-19?

In our response to COVID-19, we have moved to remote triage for all patients in primary care and have seen a rapid rise in the use of video consulting to support safe decision making.

Change has happened at great speed through the application of both workforce and digital enablers. Some of this system change in healthcare delivery is positive and should be captured and adopted for the longer-term benefit of everyone.

What has been the impact of the pandemic on the healthcare system?

A huge amount of healthcare stopped abruptly at the outset of the pandemic due to the need for strict infection control measures, and to create capacity for a huge expected surge in cases of COVID-19. Essential services for life-threatening or life-changing conditions must be maintained throughout.

Achieving good, equitable outcomes for people presenting with the non-COVID disease is of equal importance to improving outcomes from COVID-19 (and preventing the spread of infection). Maintaining essential services for life-threatening, life-changing, or time-sensitive conditions is therefore important but challenging and should be prioritised.

What role will VBHC play in the post-COVID recovery?

A focus on outcomes and value is a helpful aid to decision making as we get the wheels back on the wagon of healthcare, ensuring that we use the opportunity to ‘reset’ the system and do not return to lower value ways of working. Lower value ways of working may include outpatient follow-ups that are not strictly necessary from the patient’s perspective and also consume clinical time or interventions of low clinical value.

Post-COVID recovery will be a difficult time for healthcare as we strive to address a backlog of demand and growing need in the community. VBHC helps us to direct resources to where we can prioritise the greatest need first – and achieve the best outcomes that we can for the people of Wales.

By focusing on outcomes, we can avoid harm in non-COVID disease and ensure equity across the system.

Are decision-makers more open to VBHC?

Prior to the pandemic, we knew there was a lot of low-value activity happening that wasn’t using resources in the best possible way. VBHC is a way to identify what works well and what doesn’t – and to ensure we do more of what works.

Rising demand for services meant it was already imperative that we find sustainable ways of delivering care to patients, particularly those who are living with multiple conditions. Now, COVID is adding new pressures to a stressed system so there is fresh urgency about embracing VBHC. If there’s a silver lining to this catastrophe, it’s that we’ve been forced to press the reset button. The challenge is to ensure we have a total reboot of the system rather than slipping back into our old unsustainable patterns.

Adopting a value-based approach across NHS Wales will require investment in people and technology but will ultimately allow us to use our resources – professional time, clinical space, and money – in the best way possible.

Has the appetite for VBHC grown among patients?

Most people are not thinking about Value-Based Health Care, but vulnerable patients are certainly very positive about technologies that ensure they are cared for without unnecessary clinic visits. The pandemic has seen massive adoption of digital technology to support remote consulting and there is now a huge interest in PROMs as a way to remotely assess and communicate with patients. The pressure to change is often met with inertia. But now there is a real appreciation of how PROMs data can improve the patient experience and make services more efficient.

PROMs will help clinicians to prioritise patients and work through the backlog efficiently – without having to phone every patient individually, which is not practical. To be clear, face-to-face contacts will always be needed. The key is to treat those with the greatest need first. For example in eye disease clinics, you want to target those with glaucoma who are at risk of blindness, or people for whom cataract surgery would be life-improving.

How will COVID-19 increase demand for services?

A recent paper by Ruth Crowder, Chief Therapies Advisor to the Welsh Government, offered striking insights into the medium to longer-term needs. It groups patients into four categories: those recovering from COVID-19 in the community; those who have further deterioration in their function due to delayed intervention; people who avoided using services during the pandemic and are now at increased risk of disability and ill-health; and socially isolated or shield groups for whom the lockdown has had a negative impact on their physical or mental wellbeing.

We’re talking to the Therapies group about how we can use VBHC as a method for supporting the vast number of patients affected in various ways by the pandemic. Outcome measures that can help us assess their needs – including the EQ-5D quality of life tool, PROMIS 10 which is already used in primary care, and the WHODAS disability assessment tool. We need to collect data on samples of patients to assess their needs so that we can plan services to cope with a tsunami of rehab needs resulting from COVID 19.

Might investment in prevention, early intervention, and rehabilitation be postponed given that waiting lists have grown and budgets are stressed?

The fact is that if we don’t support people through prehabilitation and rehabilitation, they will end up at the hospital door sooner or later – often with even more serious needs. Similarly, we need to direct resources in ways that minimise inequality. All of this comes against a backdrop of a system under pressure. To me, that only strengthens the case for taking a value-based approach to ensure we invest resources wisely. The goal must be to use a robust methodology to determine which investments deliver value in terms of improved patient outcomes and reduced overall healthcare utilisation.