Muir Gray: Bye Bye Quality 2.0

Muir GrayI received some criticism for the blog Bye Bye Quality (Hello Value), as a record company might have labelled it, but most reaction was positive. Where it was not this indicated that I had not made clear enough the fact that quality improvement – doing things better –  does add value, but the issue is how much value and whether more value would have been produced by using these same resources in another way – for example simply by treating more patients at the same level of quality. This point was much better made, by coincidence, the week after my blog called Bye Bye Quality, when the BMJ published this letter from the highly experienced and respected Alan Maynard.  The letter was headlined, “Is quality of care improving? What about value for money?” and said:

“The reports of the apparent lack of success of investments in patient safety in hospitals by the National Patient Safety Agency and the Health Foundation are remarkable for their absence of economic evaluation [read editorial by Provonost et al, which the letter responded to]. Given the focus on cost effectiveness of the National Institute for Health and Clinical Excellence and public research and development programmes, the lack of consideration of value for money in these studies is reminiscent of old fashioned “effectiveness myopia.” With budget cuts and structural “redisorganisation,” the pertinent study question remains whether (and what) funding of patient safety merits shifting resources from other aspects of patient care.”

There was also a very powerful “perspective” in the New England Journal of Medicine called Cottage Industry to Postindustrial Care, which emphasised the importance of quality but gave higher status to value of the care provided, which they defined as a function of three elements; its design (the right treatment for the right patient at the right time), its execution (reliably doing it right every time to achieve the best outcome) and its cost over time.

The cost of safety improvement –  sometimes seen as part of quality improvement, sometimes as a separate topic – namely the added value of making care safer also needs to be recognised and accepted, or rejected because greater value could be obtained if the same amount of resources were invested in another service. I will report on the Case of the Nail Clipper Mountain in a future blog.

Muir Gray is visiting professor of knowledge management at the Nuffield Department of Surgery, University of Oxford.

  • Simon Opher

    I agree that value is the right thing to chase. The problem for me is who decides about the value of a pathway/procedure. Should it be public health? How can a GP be aware of all this. GPs need to be told, and not by politicians this time, and probably not by patients either. Value can be a value statement. At least GPs will know the price of everything from now on!

  • Joseph Lee

    I'm sure economic evaluation of the quality of a pathway or treatment is an important part of the evidence for that little piece of healthcare.
    I'm also sure that value for money and quality will be affected by the way healthcare is delivered, and if the policies around structures aren't backed by evidence they will get nowhere. See John Pickstone BMJ 342 p633 (… on quackery in policymaking.

    As one of the architects of EMB, how do you think we can move to EBP?

    How can we develop ways rate policy evidence for quality (currently it mostly seems to be what clinicians would consider to be worthless, expert opinon etc)? and to bring togther all availiable policy evidence about particular questions? Is there room for a Cochrane Collaboration style policy body? Or a National Electronic Library for Policy?

  • Muir Gray

    i think there is now very good work taking place on this, partly from canada eg lavis and norway eg oxman

    in england Rand in cambridge are gettibng into this space but i find it helpful to remeber that in policy making values trump evidence ; the politician can decide what they want; the official has to decide whether or not to resign!

  • Muir GraY

    about your good point ; the key thing is to know not the price but the opportunity cost