Nesta and their partners have published How should we think about value in health and care? as part of their Realising the Value project. My blog in response is here and reblogged below:
In the report, a number of strong arguments are set out for a new way of thinking about value in our public services which goes beyond consideration only of short-term symptom relief, taking into consideration the value created by people, services and communities working together. The paper recognises that this will involve finding out what kinds of value mean most to people, not just to services. This is, in my view, exactly the shift we need and it would bring with it some profound consequences.
Health is about more than buildings, staff, kit and drugs
Many of our ideas about value in health and care do not even get as far as consideration of outcomes, however narrowly and medically defined. We still behave as if the value of the NHS can be expressed in buildings, staff, kit and drugs and we reward those people and services which control the greatest quantities of those resources with the greatest budgets, salaries and ultimately power. It is not in the interests of large organisations, and those running them, to recognise the limitations of the value they are able to add to people’s lives, nor the often much greater value of the invisible economy of unpaid family care and social action. To do so would imply not just our existing institutions behaving in different ways, but some of them being phased out and their resources transferred directly to the families, communities and social enterprises best placed to define and achieve what a good life looks like to an individual with a long term condition, and to help them pursue that life.
Previously I have argued that all public services should be challenged to achieve what I am tentatively calling ‘the connection test’: alongside the relevant health, wellbeing, housing, reoffending (and so on) outcomes, to what extent does your intervention connect people to those around them? And conversely to what extent does it block or sever their connections? A service which can deliver on its core outcomes whilst maximising an individual’s connections to others, and minimising unintended disruptions in those connections, is better value for money than a service which only achieves narrow or clinical outcomes. So let’s insist that every intervention measures its positive – and negative – impacts upon people’s informal support network.
A person is more than a collection of needs to be met
Why measure ‘connection’ (and disconnection) specifically? In my view, it is one of the most telling indicators of an individual’s present wellbeing and future resilience. It is a proxy for a range of other wellbeing outcomes, such as active citizenship, full and sustainable family life, employment and so on. The extent to which a service measures and maximises an individual’s connections to others is also a good indication of the extent to which it recognises that an individual does not exist in a vacuum and is more than a collection of needs to be met.
This perhaps points towards an aspect of the arguments put in the paper which I would pursue more strongly, which is applications of asset-based or capabilities-based thinking to thinking about value. This way of thinking, developed by the Asset Based Community Development movement and others, points out that if all you look for in an individual, family or community, is need, that is all you will find and you will always conclude that an outside agency or expert is needed to fix them. It suggests that anyone offering support should always look first for what someone can or could do and should think about how to support them to maximise their capabilities and potential, drawing on their natural support networks.
At present, attempts to co-design ideas of value with people labelled ‘patients’ or ‘service users’ by ‘professionals’, will always be limited by the inherent perception of participants’ relative value and capacity to contribute. Ask an older person living in a run- down care home what they consider to be good value and outcomes in their support and they might talk about staff being polite or meals being improved, rather than a service which enables them to participate in the community or reconnect with friends. Before we can truly ‘realise the value’, we will need to raise expectations.
As independent chair of the Joint Review of the health and care system’s investment and partnerships with the voluntary, community and social enterprise (VCSE) sector, I’ll be watching the messages generated by this report with interest and would expect to see lots of synergy with the messages we are hearing through our Review. The VCSE sector has always made a huge contribution to health and care, particularly when it comes to achieving the kinds of people-orientated value for which this report argues. Investment in VCSE organisations, despite falling budgets, will be a key test of whether our health and care system understands the messages in this important report.