Book Review: How to Get Better Value Healthcare by J.A. Muir Gray

Oxford Press, Oxford, Second edition (2011)

 PP138  $27.00

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Like most of us, I have to read numerous documents from state and federal health and other statutory bodies. Some are helpful, containing useful information if you can find it. The problem with many of these publications is their length and size, including meandering preambles, numerous photographs of contented, curious and cooperative health professionals and lengthy descriptions which finally lead those few readers who have persisted thus far, to the main messages.

One cannot help wondering how often these documents are read and acted upon by those for whom they are intended. Most seem to go through a process of being written by a team of bureaucrats with help from consultants and sometimes even with input from clinicians. They go through a process of review and revision before the final version is available, ensuring that all view points are included, that they are politically correct and devoid of any humour, lightness or passion. The final 50 or 60 page glossy document becomes a very expensive project whose impact in terms of value is rarely assessed. Of course, they are available on line too but this is often a cost shifting exercise as many at the receiving end do not cope well with large documents on a screen and so print them off. In my experience, committees who write documents sometimes enhance the quality of the information but almost invariably add to the length of the text and never enrich it. It is a rare group which has a focus on brevity and clarity.

No doubt the process keeps people employed but if briefer, concise documents were produced instead, and produced only when really needed, much money would be saved. Most of it could go to where it is most needed, preventive health and patient care programs.

So with this lengthy preamble, which I freely admit is one of my gripes, it was a pleasure to read this concise book of just 138 pages.

Each chapter starts with a list of the concepts to be discussed and what the reader should understand by the end of the chapter.

As implied in the title, the book has emphasis on better value healthcare. Value is defined around the patient, not the bottom line of the balance sheet. Rather than the value of the services we provide (some of which when critically appraised may be of no or minimal value to the patient) such as the types of procedures we carry out or the throughput of patients through a clinical service, it is the health outcome for the patient which determines the value of the service.

The book starts with an outline of the challenges we now face and will face over the next ten years, describing why there is increasing demand for healthcare which is outstripping the available resources. It then gives some sensible principles for managing demand by supplying health services which produce the best value for the resources invested. There is discussion of the difference between the moral and economic meaning of value and how value may be regarded differently by clinicians, health administrators and patients. Each chapter ends with a list of questions which make the reader think. For example, the chapter on value asks, amongst other questions: If you were CEO of a big pharmaceutical company, how would you assess the value of a new drug? How could you identify a clinical service which has passed the point of optimality (the point at which the cost of obtaining additional benefits is too large in relation to those benefits) or will do so if growth is not slowed or stopped? How would you explain “More is not necessarily better” in a two-minute radio slot?

The best section of the book poses the “Top Ten Questions About Value” which should be addressed sequentially. They apply equally to a Health Department planning services, to a CEO allocating departmental budgets, to department heads wanting to introduce a new service and to any clinician who wants better patient outcomes. Here they are:

1. How much money should be spent on healthcare?
2. Is the money allocated for the infrastructure which supports clinical care at a level which will maximise value?
3. Have we distributed the money for clinical care to different parts of the country by a method that recognises both variation in need and maximises value for the whole population?
4. Has the money been distributed to different patient groups by decision making that is not only equitable but also maximises value for the whole population?
5. Are the interventions offered likely to confer a good balance of benefit and harm, at an affordable cost, for this group of patients?
6. Are the patients most likely to benefit from the interventions, and least likely to be harmed by them, clearly defined?
7. Is effectiveness being maximised?
8. Are the risks of care being minimised?
9. Can costs be reduced without further increasing harm or reducing benefit?
10. Could each patient’s experience be improved?

You will have to read the book for the answers, each of which is clearly based on economic data, and research as well as value to the population and individual patients.

If I had my time as a hospital CEO again, I would have done a better job in managing demand and helping others to plan services with the insights and practical suggestions in this book.

A review of this book in the Lancet in August 2011 (vol. 378, p.7540) suggested that it “should be required reading for every medical student in every university in the world”.  Perhaps,  but why wait for the students to become medical leaders. I’d like it to be essential reading for every department head, for aspiring heads and for nonclinical managers.

If I was in charge of appointing government health bureaucrats, the Top Ten Questions would be the basis of what I would ask at interview. Those same questions would subsequently  become the basis for the annual performance reviews of those managers and departmental heads.

 

Kim Oates
Emeritus Professor
Sydney Medical School
University of Sydney