Feature / Welsh marches

In recent years, NHS Wales has been developing approaches to healthcare that increase value to patients and deliver better outcomes in the most efficient and effective way possible. Over the past eight years, since the inception of value-based healthcare (VBHC) in one local health board, it has helped define the outcomes that mean most to patients in several clinical areas. It is now focused on bringing VBHC into the mainstream across the nation’s health system.

Local NHS organisations have been developing VBHC (see box below), and rolling this out across clinical condition areas. It now seeks to apply it to healthcare pathways across the nation, under the leadership of the Welsh Value in Health Centre and the Finance Delivery Unit.

Having developed a central infrastructure to support the system, the Wales Value in Health Centre, under the leadership of national clinical lead Sally Lewis, has launched its strategy with six areas of support for VBHC:

• Person-centred care
• Digital health
• Implementation across NHS Wales
• Communication, engagement and education
• Impact-delivering value
• Research, industry and strategic partnerships.

Dr Lewis says: ‘Prudent healthcare’s key principles of co-production, equity, intervening gently (effectively and only as much as we need to) and reducing unwarranted variation, including under- and over-treatment, are all key to achieving value for our patients and citizens across a whole system of healthcare.

‘Value-based healthcare pulls together a system of care around a particular patient pathway, where better outcomes at lower cost are achieved by doing basic things really well. It also has the potential to improve outcomes through innovation and quality improvement, and can reassure us about patient safety.’

According to Dr Lewis (pictured), the implementation of VBHC is a large cultural and transformational change that has grown from the grassroots in Wales as a delivery mechanism for prudent healthcare.

‘The principles are important in underpinning the way we reshape our services to meet the evolving needs of our population in Wales,’ she says. ‘Realising the full potential of this seismic shift in healthcare is a long-term endeavour. But already we believe that we’re beginning to demonstrate results in a diverse range of clinical areas, such as heart failure, diabetes, orthopaedics and lymphoedema.’

The NHS Wales Finance Delivery Unit is embedded in the Value in Health Centre’s work by focusing on developing the national approach from a financial perspective to support VBHC and delivering improved patient outcomes.

Hywel Jones, the unit’s director, says the value programme has taken significant steps forward, but is keen to stress that it is still far from completing the task.

‘We have done a lot of work as a system to get the infrastructure in place around value-based healthcare to support the NHS in day-to-day planning and delivery,’ he says.

Infrastructure in place

This infrastructure includes:

• A national programme for rolling out patient-reported outcome measure (PROM) capture and sharing of data nationally
• National costing data collection at patient level and time driven activity-based
  costing exercises
• A national data resource programme integrating all datasets on a national basis
• A programme of work across local health boards and national functions across a number of clinical condition areas.

‘We have made good progress but clearly there’s work left to do. The critical point is that we are creating a national framework to develop a consistent approach for developing this at scale. We also recognise that local populations and factors result in health boards implementing what they need to do locally to deliver a value-based healthcare approach to improve outcomes for patients.’

The Finance Delivery Unit, established in January 2018, is a support function that leads in a number of domains across NHS Wales. These include best practice, financial management, support and challenge to deliver financial improvement, the development of strategic financial intelligence, financial planning, and VBHC. 

Such is the progress being made by organisations, and the Welsh government emphasis on the importance of VBHC, that in 2022/23, £20m has been allocated to deliver improvements in a number of areas. These include cost and outcome data measurement, PROMs, resource allocation and distribution, reduction of unwarranted variation, and implementing evidence-based high-value interventions that improve outcomes.

This allocation complements the approach from a financial perspective, where increasingly NHS Wales is exploring how to optimise financing VBHC.

Mr Jones says it is exploring three main areas – how to finance value at an allocative level on a system basis (from government to local health boards), how to allocate resources within organisations across pathways and clinical condition areas, and how the NHS uses its resources with partners, be that purchasing, industry or other public sector organisations, with a view to improving outcomes. 

He believes there is no single approach to allocating resources that will increase value but a combination of approaches, which will vary depending on clinical condition and the changes required to improve outcomes.

Practical steps

In practical terms, there are a number of elements to this approach. The first is finance teams working together and directly with national clinical leads to develop the cost and outcomes data using a range of techniques required to identify improvements within clinical condition areas.

‘This is about putting finance and clinicians together to interrogate data using a range of techniques in a sophisticated way. The aim is to give clinicians insight into the unwarranted variation and high-value interventions that will improve value and patient outcomes,’ Mr Jones says.

Through these relationships, the Finance Delivery Unit and the National Value in Health Centre are producing a range of new products to tease out the clinical challenges, and ensure the right information is developed to focus on the actions required to drive value.

These products are increasingly being supported by the advances in collection and integration of a range of datasets. This includes collecting comprehensive PROMs and patient information across Wales, patient-level cost data, population health data and hospital admissions data.

A national data resource (NDR) is being developed to ensure that all of this data is integrated into one data repository and the information is being tested to ensure that
the right approach is taken and the evidence base is robust.

Health boards have the autonomy to develop their own approach to meet the needs of their population, but within a common framework and using some of the national data to provide actionable insights at a local level.

NHS Wales is putting a number of steps in place to support the implementation, including a value finance leadership group, which meets fortnightly, made up of the Finance Delivery Unit, the Welsh government and health board finance directors.

Similarly, the national VBHC team has developed a network of implementation leads, and system oversight is supported by a group of executive leads led by a health board chief executive. As a result, these networks are developing to ensure all activity across Wales that involves evidence-based high-value interventions is collected and captured to support spread across the system.

Key partners

Mr Jones says NHS Wales partners with several bodies at national and local level to support implementation. The approach being implemented allows a focus on outputs, with a view to ensuring data can be shared in a consistent manner.

‘From an outcomes perspective, we are focusing increasingly on capturing PROMs in a consistent manner, with consistent standards, irrespective of what the data infrastructure used to capture that is,’ he says.

‘We are merging different products across the system to do this on an all-Wales basis. We have a PROM standard operating model developed by the national team and this is supporting progress with this agenda.’

Mr Jones adds: ‘Having existing systems enables the capture of the information, but we will also be able to consider different outputs in a single reporting repository.’

A good example of how data from multiple datasets has been integrated to support this agenda is the Finance Delivery Unit’s development of the Diabetes insight and variation atlas. ‘We pulled together all the existing data into an easy-to-use product for the system,’ says Claire Green, deputy director of finance at the Finance Delivery Unit.

She also leads the development of the product, working with national clinical lead Julia Platts and the unit’s head of financial analysis Kimberley Rowe.

Data from a number of areas has been integrated and the Finance Delivery Unit has also brought in clinical outcome data, population data and information on adverse outcomes in specific sub-specialty pathways.

‘We want to address adverse clinical outcomes through prevention, and upstreaming higher-value intervention,’ says Ms Green. ‘We are beginning to make progress. We are identifying high-volume interventions that will have the greatest impact on patients as well as maximising our utilisation of resources. This will mean doing things upstream and not having all the resources where they have been traditionally utilised at the end of the pathway.

‘We are building a fantastic data product that is useful for clinicians and the system. We now need to use real clinical outcomes to highlight areas of variation where we can commit to prevention activity on a national basis consistently.

‘Or, where we know the standard of care, we should be delivering information for local health boards to make progress in implementation and improving outcomes.’

VBHC in NHS Wales has attracted considerable international interest, and the NHS Wales Value in Health programme is one of the global innovation hubs of the World Economic Forum (WEF) global coalition for value in healthcare. The WEF value in healthcare programme includes peer-to-peer network communities, one of which is finance, and lived patient experience.

Mr Jones says participating in the finance network is helping to shape VBHC in Wales. This network provides an excellent opportunity to share learning and experiences of implementation with a range of other stakeholders from different sectors and industries, across different healthcare systems.

Steve Elliot, Welsh government health and social services group interim director of finance, says: ‘A continued momentum in adopting value-based healthcare in Wales is a priority for the Welsh government and supports our commitment to achieving the vision and ambitions set out in A Healthier Wales, our plan for health and social care.

‘It also contributes to the government’s commitment to addressing the delays in planned care as a result of the pandemic and forms a critical component of our financial strategy to ensure that the allocation and use of NHS resources in Wales is driving improvements in health outcomes for our citizens.’

Value journey