Value and Carbon


Value is a concept which is making waves in the management / leadership / policy world of medicine at the moment.  It is not an entirely new concept, but has been worked on and promoted as an approach to the management of healthcare which will unite providers, commissioners, and payers in healthcare economies across the globe.

Michael E Porter has been looking at this area for some time, and has defined value as:

outcomes / $ spent

This deceptively simple equation helpfully focuses the mind on the numerator of outcomes – specifically those important to the patient – and cannot only be improved only by cutting at the denominator.

A recent seminar at City Hall in London (see here for slides from the talks) explored this idea further, highlighting to a number of prominent leaders from the world of medicine how this concept of value unites different actors in the system around the thing which matters – outcomes for patients.

Porter gave six steps in a strategy to realign objectives along the value agenda:

1.  Organise into Integrated Practice Units around patient medical conditions

2. Measure outcomes and cost for every patient

3. Reimburse through bundled prices for care cycles

4. Integrate care across separate facilities

5. Expand areas of excellence across geography

6. Build an enabling Information Technology platform

Of these 6 steps – one of the most complex is probably the costing of care.  This is not simply the tariff, or the invoiced cost,  but the true costs of each care cycle (this may be a short emergency admission, or a year of chronic condition care – depending on how the care is bundled up)

One cost of healthcare which at present is often hidden away, and not really counted in business cases, service proposals etc is the carbon cost of care.  Carbon useage has been estimated for the whole of the NHS (with updates regularly – here is the 2012 update– one of the first healthcare systems in the world to take this important step to understanging the impact of care on the environment.   It is not so simple to find out what the carbon costs of individual episodes or cycles of care – or what the solutions might be.

Understanding this aspect of care cycles is going to be increasingly important with the introduction of league tables of carbon useage (find your organisation on the current table here)  and with the UK having legally binding targets for reducing carbon consumption ( we  have a target to reduce CO2 emissions by 80% from 1990 levels by 2050 – and in the meantime need to get down to 34% of 1990 levels by 2020 – not that far away)

Simple efficiencies are not likely to make huge differences to the overall footprint – but re-examining the way we ‘do’ medicine could – building use makes up 19% of the current footprint, whilst procurement still makes up 65% – and pharmaceuticals making up the lions shar of this.  Frances Mortimer explored this in an opinion piece published in 2010 – and there remains considerable doubt about what could be done.

Respiratory disease is a major burden to the NHS (pdf), and the UK economy – £6.6 billion pounds spent on it in 2006, and around 1 in 5 people dying of respiratory disease (more than ischaemic heart disease for example)  The chronic nature of many respiratory diseases, characterised by periods of stability, punctuated by dramatic episodes of illness make it a complex care model to decipher.  However, the fact that respiratory disease – and in particular COPD can be both prevented, and ameliorated by non-pharmacological means, improved self-managment and better organised care make this area one of huge importance if we are to understand and control the carbon costs of the NHS.

I am pleased to be working with the Centre for Sustainable Healthcare on a project to determine what the carbon costs of different care models are for COPD, and use this to help focus the minds of commissioners when it comes to defining high value treatments and strategies for addressing respiratory disease.

It would be great to have your opinions and ideas about how respiratory care could be made more efficient, or if you think that counting carbon could help to discriminate between care models, and help us to improve not only the quality of respiratory care in the UK, but also enhance the value we can offer patients through smart commissioning.

Please visit the Centre for Sustainable Healthcare and sign up to the networks they have there to get the latest news and resources to inform your practice, and see how you can help to improve the services we offer – in terms of value, quality and carbon.


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