the low value care problem

The “low value care” problem

I use this term advisedly!


  • Basic options

  • Data – spend and activity

  • Culture – its really important.

  • Careful re the over focus on “lists of stuff” and schemes, at expense of culture and organizational incentives?

  • Implementation

  • The provider model – the dealbreaker



1          Basic options


  • Demand v supply – ideally got to address both
  • Closing down capacity – to address the supply issue. Seems ok, but needs to be squared with choice.
  • Death lists, lists of low value interventions – I am far from convinced that per se, they are of much value. Becomes and issue of how they are used in practice.
  • Stopping interventions – can we, should we?
  • Alternative pathways
  • Price lists – to influence culture, patient and clinician.
  • Organisational form – a big deal, difficult, risky, high reward. Little empirical evidence – emerging from the states. Questions of Scope – Is prevention and lifestyle change “in”
  • Is it ONLY about what happens in hospital, or is it about what happens in hospital and non hospital.
  • Is LTC “in”

2          Data


national programme budget dataset as a decent place to start when looking at comparative spend

Attached are some pretty graphs. This is from the Programme Budget dataset 14/15 (I need to check – might be 13/14)

All the normal weaknesses


The data q has improved a lot over the years.

The algorithm that its based on gives a sense of spend according to the activity data that each CCG feeds in.

the SPOT tool ditto to guide relative outcomes.


Activity data – whats it telling you

From contract – only gives you local.

This tells you little to nothing about where you stand comparative to others

Short cut for that is NHS Atlas and similar – but doesn’t cover that many areas


Other interesting and useful data is the RCS procedures explorer tool.

There’s the issue of total volume, where are we outliers etc. A small change in a high volume thing will make more difference to a large change in area where outlier that’s low volume etc.

3          Culture


Patient culture

changing attitudes and patient expectations.

Calcium supplement / Vitamin d / Paracetomol – OTC vs FP10.

How much do we spend on FP10s for products that can be purchased for tuppence a bucket. And in the case of vit d / ca increasingly tells us doesn’t do much good)

How many extra phsyios could you buy with that cash etc



Building self care into the routine way of doing stuff.

Kirklees have 5 distinct questions they encourage all patients to think about – they are brilliant!

best one I saw recently was around a GP focused campaign to get all patients to ask their doctor these four questions at all critical moments – before new treatment commenced / before referral for treatment or opinion:

Do I really need this test or procedure?

What are the risks?

Are there simpler, safer options? (Very often changing lifestyle will be just as or more effective.)

What happens if I don’t have the test or procedure?

How much does it cost?


Where’s the shared decision making as part of this – it makes a difference (though it’s a bit hard to quantify). Plenty of anecdote of  a CCG using the RightCare shared decision aids for OA hip and knee as a pre-requisite before referral for knee and hip replacement, and the anecdote was amazing reductions in short term rates of referral. There are many NHS Rightcare decision aids, there are many other excellent decision aids.


Changing the culture towards one of healthy living.

Eg Patient expectations re stuff low back pain – go walking rather than go see yer GP….will do you far more good



Balance between state and individual

Re striking the balance between state funded care and what’s individual responsibility

State is shrinking – whether we like it or not

Need to re strike the balance – state will continue to meet need, but your part of the deal is…….


Clinician culture

The extent to which clinicians see themselves as steward of resources.

Especially relevant to secondary care

Do they really own the issue of resource stewardship for the whole population

Is there a diabetes doc who has a PA for the work involved, and responsibility for proactively managing the concept of population medicine for the whole of the diabetic population of xxxxxxxx. So direct clinical care for complex, advising GPs on the majority of tricky where there is a need and actively managing the budget and quality / outcomes.


Alignment of incentives

If lucentis was not a tariff excluded drug, the trust and likely the clinicians within it would feel very differently about use of avastin.


4          Careful re the over focus on “lists of stuff” and schemes, at expense of culture and organizational incentives?


These hold intuitive appeal. They are a visible emblem of “low value”


Many clinicians rail against “lists of stuff” – so whilst initiatives such as Choosing Wisely on the face of it have great traction, and are indeed owned by different specialties – they by themselves wont change much.


there’s already a backlash from grass roots GPs around “do not do” lists and the like…..

“lists” wont change the way that the business gets done, or how individual clinicians think.

List based approaches are often criticized for basically trying to create new “rules” without changing the fundamental issues. Read the recent BMJ Knee washout article. When the evidence is less clear, or contested, lists are even less likely to be successful.


however ultimately someone has got to come up with a starting point

exacerbated by the fact that there isn’t a single big idea…. there are lots of little ideas….. someone somewhere has got to identify the little ideas…….thus emphasis on lists


How I’d recommend you use a “list” is in the context of a detailed discussion with a varied group of clinicians after having reviewed the current spend and set of services in an area, this is how we managed the programme budget conversations.


The Evaluation of the USA Choosing Wisely programme is instructive on the limitations of “lists”



Don’t forget the RCS tools and policies for specific procedures

Some great stuff in there

Data and RCS led policies and advice.



Production of “top tips” – by GPs for GPs – specialty focused set of tips for commonly occurring issues to help GPs and guide them. Single side

Patient focused top tips



the culture stuff among clinicians is huge…. and not to be under estimated

Alternatives to the traditional “list”

Most recently published in BJGP – Ten Commandments of new therapeutics. Lehman BJGP October 2015.

A similar version of this exists for diagnostics.



RCGP Over diagnosis group have also created a GP facing list.




5          Implementation


  1. a) Active implementation is the only way. Passive wont cut it.

A policy, production of a pathway, a guideline – by itself will achieve no change

Referral management – the evidence tells us will achieve no change. Everyone tells me that “it will be different this time” – I hope so

Programme management – goes without saying?

Long term sustained approach needed – we are normally half good at piecemeal and patchy.


  1. b) Should we come back to PBMA

Everyone hates it. Its hard. Should we come back to this……we learned a lot last time we did it. We failed for 2 reasons 1) PCT fell apart 2) nobody was interested in implementation – I couldn’t do it by myself 3) we didn’t have the contractual means to make it stick


In five points.

  • systematic analysis of whole of spend in whole of a clinical area.
  • With clinical input.
  • Systematic identification of wish and hit lists.
  • Nothing on the wish list till the hit list implemented
  • Focus on the organisaitonal infrastructure to implement.c)         “referral management” centres.There is a decent evidence review on “managing demand” from Sheffield.There IS scope, significant scope, for more nuanced approaches say involving audit, feedback and education – both one to one academic detailing for a practice and wider mass education events. This is largely untested evidence wise in THIS context, but plenty of evidence from the wider QI literature. The current model is obviously micro managing lots of disjointed contracts versusMake the clinicians feel the need to look for value and transfer the responsibility to them.Don’t be “commissionery”……….. reckon doomed unless ownership and buy in from sec care clinicians as well as prim care clinicians (with their provider hat on
        • the levers are too weak
          • Act strategically as a PAYER and either set price for procedure, for bundle of care or total volume of care for a population of patients – and hold people to that price with contracting method.
          • e)         Role of commissioner
            • Read it, understand it, act accordingly.
            • There’s decent evidence they add cost but make no difference



            6          The provider side of the question is perhaps the most important


            if there is a big idea it is basically complete change to the provider model


            The fundamentals of hospital economics – if Chief Exec has got x orthopod and y cardiologist salaries to pay etc…..

            This, for me at least, is the dealbreaker

            The issue of whether “closer to home” is cheaper is simply not a settled one….. lots of evidence that it isn’t…. it’s a v nuanced q.

            How we transform the outpatient model – 50% to be “saved” here, tho doesn’t solve the provider side issue


            Is completely different model of provider in or not in

            Ie whole population model – blended general practice / hospital / community care – ie accountable care.

            Yes of course it’s a big deal.


            Factory surgery

            Eg Bradford does O&T, CHT does opth, MYT does gynae etc etc

            I would reckon a step too far? And complex to deliver. Certainly been some discussion about it at leaders meetings locally.


            Organizational form – multiple suppliers, complex purchasing arrangements and fragmentation vs single provider model.

            This is Accountable Care.

            Schwartz (JAMA Intern Med September 21, 2015) highlighted the potential for addressing the “low value care” issue with new models of provider. There were modest reductions in the use of low value services, leading to a conclusion that Accountable care organization–like risk contracts may be able to discourage use of low-value services even without specifying services to target.

            The first year of ACO contracts was associated with a differential reduction of 0.8 low-value services per 100 beneficiaries for the ACO group, corresponding to a 1.9% differential reduction in service quantity and a 4.5% differential reduction in spending on low-value services.



            Ultimately it IS about transference of risk from payer to provider… yes, to answer Matt’s point directly… IS about passing the problem, but arguably to a part of the system with more direct control of the solution.

            uncomfortable that is, but its probably the direction of travel across the world

            and probably appropriate

            and the role of the commissioner becomes very much more strategic than it currently is and works with the provider to build the tools of population health management etc



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