{"id":38204,"date":"2017-01-20T13:02:22","date_gmt":"2017-01-20T12:02:22","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=38204"},"modified":"2017-01-30T09:24:27","modified_gmt":"2017-01-30T08:24:27","slug":"tessa-richards-power-to-the-people-via-paris","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2017\/01\/20\/tessa-richards-power-to-the-people-via-paris\/","title":{"rendered":"Tessa Richards: Power to the people\u2014via Paris"},"content":{"rendered":"

\"Tessa_richards\"<\/a>Who gets to define value in health systems? The notion that it should be the people who use their services, rather than those who provide them, is gaining momentum. At a meeting in Paris this week, convened by the Organization for Economic Co-operation and Development (OECD), revolutionary zeal was in the air as speakers urged health ministers to back the nascent science of \u201cmeasuring what matters to patients,\u201d and use the metrics to improve the performance of their systems.<\/p>\n

The politicians listened. After a closed debate on the challenges facing health systems, led by Jeremy Hunt, secretary of state for health in England, ministers from the 35 OECD countries and nine other countries signed a lengthy statement on the \u201cNext generation of health reforms<\/a>.\u201d\u00a0It includes a pledge to support the systematic collection of validated and comparable cross country \u00a0indicators of service quality and value\u2014as defined by patients\u2014and use them as a yardstick to compare health systems performance.<\/p>\n

That the idea of ranking a country’s health system by how much patients and the public believe they deliver should be regarded as revolutionary, speaks volumes. Not just about the nature of healthcare, but also the power imbalance between patients and health professionals.<\/p>\n

But old hierarchies are changing. Public trust in health services and the professionals who work in them is waning. There is growing awareness and concern about health systems<\/a> wicked problems:\u00a0inequity in access to services, high rates of avoidable error, and the overuse of tests and treatments.<\/p>\n

\u201cWe have got to the stage,\u201d Don Berwick of the Institute for Healthcare Improvement, warned in an early salvo to the meeting, \u201cwhere society is saying what\u2019s going on in healthcare? Healthcare professionals feel threatened.\u201d<\/p>\n

Recent publications on the level of waste and harm in health systems include the OECD\u00a0 report published last week on \u201cTackling Wasteful Spending on Health.<\/a>\u201d\u00a0Angel Gurria, secretary general of OECD, an impressive speaker with a Reverend Ian Paisley style of delivery, fired off some of it\u2019s depressing statistics.<\/p>\n

\u201cThe poor are ten times more likely [than the rich] to report unmet health needs for financial reasons. One in ten people are effected by preventable disease, error, or substandard care. One in four experience poorly co-ordinated care,\u201d he said. Only one in four? A few participants murmured<\/p>\n

He went on.\u201cWe must stop judging health service performance by what services do,\u201d he said. \u201cWe need patients to tell us if and how the services they access improve their physical health, mental health, functional status and quality of life.”<\/p>\n

The OECD has recently published<\/a> the recommendations of a high level expert group on how to collect reliable internationally comparative data that provides a better indication of the outcomes of care from the patient’s point of view.\u00a0Now it has the mandate to advance the so called PaRIS (Patient reported indicators of health system performance) work which it\u2019s doing in partnership with ICHOM<\/a>, the International Consortium for Health outcomes.<\/p>\n

As with all metrics, the devil is in the detail. There is undoubtedly much to be learnt from systematically collecting PROMS and PREMs (patient reported outcomes and experience measures). But as Diana Delnoij, from the Netherlands National Health Care Institute underlined, the science of how to measure them must be improved, and patients fully involved in deciding what to measure, and how.<\/p>\n

New indicators are needed, she suggested to assess performance that matters to them such as \u201cbeing treated with respect, and receiving co-ordinated care.\u201d<\/p>\n

They also value continuity, good relationships with staff, being supported and empowered to self manage their own care, and better use of digital technologies. Giving patients access to e-health records so they can input PROMS and PREMs in real time, should help, other speakers suggested.<\/p>\n

But it will take more than a TripAdvisor approach to gain full insight into patient’s perspectives of good quality care and identify the outcomes they value. Preferences, priorities, and expectations can change over time, especially for patients living with long term conditions, as Atul Gwande\u2019s recent compelling article on Incremental Care<\/a>, illustrates.<\/p>\n

Gwande describes the case of Bill Haynes (not his real name), a 57 year old man with uncontrolled and hugely debilitating migraine. Since the age of 19 he saw many doctors and tried a panoply of medications and whacky \u201ccures.\u201d Some gave short term benefit, and \u00a0\u201creal time\u201d PROMs and PREMs measures would likely have recorded that. But none helped in the longer term. What has is meeting Elizabeth Loder, a neurologist who runs a specialist headache clinic (and also works for The BMJ as <\/em>Head of Research) .<\/p>\n

She listened to his story, exuded \u201cconfidence and a maternal concern,\u201d\u00a0suggested she could help, but that he needed recalibrate his expectations. At repeat visits, she provided support and made minor incremental changes to his regime. Over time, it changed his life around. The challenge for metricians is to capture the benefits of a service like this, because from the patient\u2019s perspective it\u2019s\u00a0like gold dust.<\/p>\n

Michael Porter, professor at Harvard Business School, was not in favour of an incremental approach to developing and using patient reported indicators.<\/p>\n

\u201cThe only definition of a successful\u00a0health system is one that produces value for patients. We must establish global standard sets of outcomes, condition by condition. There is no excuse for inaction,\u201d he said.<\/p>\n

Could PaRIS (Patient\u2011Reported Indicators Survey (PaRIS)<\/a>\u00a0become as influential in spurring effective reform of health systems as PISA appears to be in education? (PISA is the tool the OECD uses to rank countries by 15 year old\u2019s reading, maths, and science skills).<\/p>\n

For patients and health professionals weary of \u00a0the promise of \u201cnew tools and reforms to transform\u201d health care we can only hope so.<\/p>\n

Tessa Richards, <\/strong>Patient partnership editor, The BMJ<\/em>.<\/p>\n