Value-based healthcare is

the equitable, sustainable

and transparent use of the
available resources to
achieve better outcomes
and experiences for every
person

Defining
Value-based
Healthcare
in the NHS

Centre for Evidence-Based Medicine Report 2019/04

 Defining Value-based Healthcare in the NHS: CEBM report

Defining Value-based Healthcare in the NHS

Hurst L, Mahtani K, Pluddemann A, Lewis S, Harvey K, Briggs A, Boylan A-M, Bajwa

R, Haire K, Entwistle A, Handa A and Heneghan C

CEBM, University of Oxford

Report Authors
Louise Hurst - Senior Associate Tutor and Research Fellow, Centre for Evidence-Based Medicine, Nuffield
Department of Primary Care Health Sciences, University of Oxford
Dr Kamal Mahtani - GP and Associate Professor of Evidence-Based Medicine, Nuffield Department of
Primary Care Health Sciences, University of Oxford
Dr Annette Pluddemann - Senior Research Fellow Centre for Evidence-Based Medicine, Nuffield
Department of Primary Care Health Sciences, University of Oxford
Dr Sally Lewis - National Clinical Lead for Value-Based and Prudent Healthcare, Aneurin Bevan UHB and
Honorary Professor, Swansea University Medical School
Kate Harvey - Service Director - Children, Young People and, Dorset Healthcare University NHS
Foundation Trust
Dr Adam Briggs - Public Health Specialty Registrar, the Health Foundation
Dr Anne-Marie Boylan - Departmental Lecturer and Senior Research Fellow NIHR CLAHRC Oxford,
Nuffield Department of Primary Care Health Sciences, University of Oxford
Dr Raj Bajwa - GP and Chair, NHS Buckinghamshire CCG
Dr Kate Haire - Clinical Director, Guy's Cancer and Partners, SEL Accountable Cancer Network and Joint
Clinical Chair SEL Cancer Alliance
Andrew Entwistle - PPI contributor
Professor Ashok Handa - Director of Surgical Education, Associate Professor in Vascular Surgery,
Consultant Vascular Surgeon and Training Programme Director (Vascular Surgery), Nuffield Department
of Surgical Sciences, University of Oxford
Professor Carl Heneghan - Professor of Evidence-Based Medicine and Director, Centre for Evidence-Based
Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford

How to cite: Hurst L, Mahtani K, Pluddemann A, Lewis S, Harvey K, Briggs A, Boylan A-M, Bajwa R, Haire
K, Entwistle A, Handa A and Heneghan C. Defining Value-based Healthcare in the NHS: CEBM report May
2019. https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/

Attribution
CC BY

1
 Defining Value-based Healthcare in the NHS: CEBM report

Foreword
Evidence-based medicine describes the need for “the more thoughtful
identification and compassionate use of individual patient’s
predicaments, rights, and preferences in making clinical decisions
about their care.” 1 1997 saw the Centre for Evidence-based Medicine
publish both Evidence-based Medicine, How To Practice and Teach It 2
and Evidence-based Healthcare, How To Make Health Policy and
Management Decisions. 3 The latter used the term value based
healthcare for the first time in its second edition in 2001, 4
emphasising “those who pay for healthcare will require that
interventions are provided only when their outcomes give greater benefits than any other
alternative use of resources.”

The Centre has, over the years, demonstrated and advocated against the potential harms of
“too much medicine” 5 and poor regulation of treatments 6 and research. 7 It has used evidence
to show where healthcare resources may be wasted (e.g., Tamiflu 8) and costs could be saved
(e.g. open prescribing 9). All of these examples show how evidence can be used to increase
value in the use of healthcare resources.

Shortly after the Centre was established, the election of the Tony Blair government in 1997 led
to a decade of unprecedented growth in NHS investment. Decision makers found all the
pressure was off. It was not until the culture change induced by the Lehman Brothers collapse
in 2008 that population value became an explicit element in decision making.

Today, “up-to-date decision-making in health care around the world” must consider value as
well as evidence. Evidence-based medicine and evidence-based healthcare have been two sides
of the same coin for twenty years. So, too, are personal value and population value. Value for a
population is determined by both the allocation and the use of resources to optimise health and
minimise inequity. This report explores the key issues and brings together both evidence and
value in decision making.

Sir Muir Gray

University of Oxford
2019

2
 Defining Value-based Healthcare in the NHS: CEBM report

Table of Contents

Summary ............................................................................................................................................... 3
Seven Key recommendations ................................................................................................................ 4
Why do we need to define value-based healthcare for the NHS? ......................................................... 6
Our approach ......................................................................................................................................... 7
1. Meaning of value in the NHS ......................................................................................................... 7
What do we mean by value-based healthcare in the NHS? .................................................................. 8
2. The key challenges and barriers to value-based healthcare in the NHS ....................................... 9
3. Skills and training needed to deliver value-based healthcare ..................................................... 10
Conclusion ........................................................................................................................................... 11
References ........................................................................................................................................... 12

Summary

‘Value’ is gaining prominence in healthcare systems facing increased demand for services with limited
resources. However, value-based healthcare has not yet been embraced as part of the everyday
language and business of the NHS in the way that evidence-based healthcare has.

The absence of an agreed definition of ‘value-based healthcare’ in the NHS, the lack of skills required to
deliver value-based healthcare and a clear understanding of the barriers to effective development and
implementation inhibits the health system in addressing problems such as overdiagnosis, too much
medicine, poor allocation of resources and the introduction of inadequately evidenced technologies

This report sets out a route to defining value-based healthcare in the NHS, an assessment of the barriers
to its development, and an understanding of what skills and training would support implementation. A
stakeholder workshop informs the report with patients and leaders across the NHS and value sector.

Definition: Value-based healthcare is the equitable, sustainable and transparent use of

the available resources to achieve better outcomes and experiences for every person.

3
 Defining Value-based Healthcare in the NHS: CEBM report

Seven Key recommendations

For patients and professionals in the NHS who are interested in increasing value at a local or national
level:

1. Adopt a common terminology so that every person involved in healthcare, including patients, has
a shared understanding of what value-based healthcare is.

2. Identify and communicate unwarranted variations in healthcare to every person, ensuring

genuine transparency about why value-based healthcare is essential, and why realistic decisions
based on the available resources are required.

3. Recognize and develop strategies to overcome barriers to implementing value-based healthcare

at the individual, team and organisational level.

4. Build capacity and capability to translate and implement the best available research evidence into
effective action to increase value.

5. Develop the necessary skills in value-based healthcare by training staff in how to measure
outcomes, patient experience and resource use

6. Ensure programmes to increase value are monitored and evaluated to provide better evidence
about what is and isn’t effective

7. Facilitate better communication and dissemination about what works in increasing value at a local
and national level.

Why we need to consider value in healthcare?

The relationship between the resources used and outcomes achieved in healthcare is under greater
scrutiny. Resources are increasingly outstripped by demand for healthcare, [10] driven by changing
population demographics, innovation and new technologies, patient expectations and an increase in
multi-morbidity [11]. Adding to this pressure to meet ever-increasing demands, the NHS is underfunded [12]

and overstretched. [13] Yet, evidence suggested that resources are all too often wasted. [14]

Unwarranted Variations

“Unwarranted Variations” in healthcare describe differences in resource allocation, resource use or

outcomes in health that aren’t explained by patient preference or illness. [15]

4
 Defining Value-based Healthcare in the NHS: CEBM report

In Clinical Commissioning Groups (CCGs) in

England, the rate of CT investigations varied from
34 to 163 per 1,000 weighted population. A 4.6-
fold difference between CCGs.

It is currently not clear what the level of CT

activity for a population should be, but both
underuse and overuse of CT scanning could be
harmful to patients (high doses of radiation are
associated with CT scanning).

‘The magnitude of variation for many of the

indicators in this Atlas may surprise some
people. In a context of evidence-based
medicine and guidelines, how is it possible
that the degree of variation in diagnostic
testing is so great?’
The 2nd Atlas of Variation in NHS Diagnostic
Services in England

Evidence that unwarranted variations exist in the NHS is set out in the NHS Atlas of Variation [16]].
Unwarranted variations are associated with overuse or underuse of health technologies and care. [17]
Underuse and overuse of tests and treatments is a global phenomenon. [18] [19] [20] And while the NHS has
mechanisms to protect against this; it is not immune. [21] Unwarranted variations in care exist, persist and
affect all aspects of care. Lord Carter’s review of the ‘operational productivity and performance in English
NHS acute hospitals’ estimated that if we reduced unwarranted variation at least £5bn of the £55.6bn
spent annually by acute hospitals could be saved. [22]

Unwarranted variations show where NHS resources might be wasted, where patients may be
harmed through underuse or overuse of care and highlight opportunities to increase value.

CASE STUDY: Openprescribing.net, from the EBM Datalab, monitors patterns of prescribing for
doctors, managers and anybody involved in the NHS in England to use. The research has identified
that:

● NHS doctors in England are prescribing more and stronger opioids and that there are
unwarranted geographical variations in the prescribing patterns of these drugs [23]
● Although doctors are generally prescribing fewer treatments from a list identified as “low
value” by NHS England, the overall cost of prescribing them has increased and prescribing
varies widely by treatment, geographic area and individual practice [24]
● The extent and speed of implementation of new prescribing guidelines on a group of antibiotics
for England (aiming to limit increased antimicrobial resistance) varied across the country, by
clinical commissioning group [25]

5
 Defining Value-based Healthcare in the NHS: CEBM report

The Right Thing to Do

The NHS is a tax-funded resource and therefore has a moral obligation to use its resources as efficiently
and effectively as possible. A survey of public attitudes found that for people who were dissatisfied with
the NHS, the top three reasons given related to access and resourcing - 33 per cent identified waste as a
reason. [26]
Furthermore, the NHS must address health inequalities in access and outcomes. And improving outcomes
for patients presents opportunities for greater clinical stewardship in the management of resources. [27]
Increasing value will reduce waste, improve health outcomes and reduce health inequalities with the
available resources.

Why do we need to define value-based healthcare for the NHS?

Interest in value-based healthcare has increased significantly in the NHS with several high profile
programmes set up to address unwarranted variations and their causes. For example, “Getting it Right
First Time” [28] and “RightCare” in England. [29] “Realistic Medicine” in Scotland [30] and “Prudent
Healthcare” in Wales [31] all aim to reduce waste and centre patients in decision making.

‘Getting it Right First “A national programme designed to improve the quality of care within the
Time’ NHS by reducing unwarranted variations.” [32]

‘NHS RightCare’ in “The NHS RightCare delivery methodology is based around three simple
England principles of working with local systems;
● Diagnose the issues and identify opportunities with data, evidence
and intelligence
● Develop solutions, guidance and innovation
● Deliver improvements for patients, populations and systems” [33]

‘Realistic Medicine’ in “Realistic medicine aims to improve care and treatment it offers by:
Scotland ● “Sharing decision making between health professionals and
patients
● Providing a personalised approach to care
● Reducing harmful and wasteful care
● Collaborative work between health professionals to avoid
duplication and provide a joined up care package that better
meets needs and wishes” [34]

‘Prudent Healthcare’ in “Healthcare that fits the needs and circumstances of patients and avoids
Wales wasteful care”.
“Any service or individual providing a service should:
● Achieve health and wellbeing with the public, patients and
professionals as equal partners through co-production
● Care for those with the greatest health need first, making the
most effective use of all skills and resources
● Do only what is needed, no more, no less; and do no harm
● Reduce inappropriate variation using evidence-based practices
consistently and transparently.” [35]

6
 Defining Value-based Healthcare in the NHS: CEBM report

But value-based healthcare is far from fully embedded in the NHS. Evidence suggests that the adoption
of programmes to increase value to date has been piecemeal [36] and that their projected impact may
have been exaggerated. [37] Case studies show that NHS Trusts seeking to increase value take different
approaches which can vary from small innovations to whole scale systemic changes [38].
The NHS Constitution enshrines that ‘The NHS is committed to providing best value for taxpayers’ money’
[39]. Yet, there is no agreed consensus on what defines value in the NHS and what “value-based”
healthcare in this context means.
The most well-known definition of value is ‘the health outcomes achieved per dollar spent’. [40] but this
description has limitations in the context of universal healthcare systems funded through social insurance
or taxation. Focusing only on funds spent on each patient’s cycle of care does not take account of the
available resources and how they are allocated across the whole population.
An essential component of value-based healthcare in the NHS must be the process of making judgements
about the allocation and use of resources. At a national level, the NHS has systems of resource allocation
in place, such as the National Institute for Health and Care Excellence (NICE) and a national formula to
weight the distribution of financial resources. However, decisions about resource allocation are also
required at an organisation and individual (patient) level. Daily value decisions are taken by NHS
commissioners, managers and by clinicians, although they may not be recognised as such. NHS clinicians
incorporate evidence about effectiveness into their decision making but do not yet routinely consider
resource allocation and opportunity costs in their decisions. Any definition of value, therefore, must be
applicable to, the range of stakeholders active in the system and take into account the role of resource
allocation.
To address this, technical, allocative and personal aspects of value in the NHS have been described, [10]

but each of these terms require further explanation to be clearly understood.

There are no consistent definitions of value or value-based healthcare in widespread use
that are succinct and take into account that “resource use” in the NHS incorporates both the
application and the allocation of resources to achieve health outcomes.
Engagement with value-based healthcare has not been as widespread in the NHS and research as might
be expected, we believe in part because there is no clarity about what value-based healthcare means and
how it applies to decision making. Further, the barriers to value-based healthcare are poorly delineated
and understood, and there is a lack of clarity about the knowledge, skills and training required to develop
and deliver value-based change.
Our approach
We invited a range of stakeholders with an interest and experience in healthcare value and the NHS
(commissioners and providers, academics, patients, thank tanks and a healthcare value social enterprise)
to a workshop to address these issues. Emerging themes were captured to answer three core questions:
1. What do we mean by value in the NHS?
2. What are the key challenges and barriers to value-based healthcare in the NHS? and
3. What skills and training are needed to deliver it?

1. Meaning of value in the NHS

“Resource Use” not “Costs”: The term “costs” can have economic and negative associations.
“Resource use” was preferred because not all “costs” are financial. Patient care can require the use of
personal, societal and environmental resources. These examples highlight that resource use today, can
have implications for future resource availability and demand. Resource use can also prove to be a
positive process, for example, NHS staff are a high-value resource and making the best use of their time
is more likely to provide job satisfaction and support their well-being.

7
 Defining Value-based Healthcare in the NHS: CEBM report

Personal, societal and environmental resource use associated with healthcare

Personal (patient) The burden of treatment, discrimination

Health and social care, the burden of care (for carers), loss of productivity,
Societal
welfare and pension costs

Environmental Carbon, pollutants

Focused on Outcomes not Outputs: Value should focus on outcomes that matter and make a
difference to patients. Defining outcomes, reframing services to measure and prioritise outcomes that
matter is essential to increasing value. Collecting data about experiences and outcomes has gained
currency in the NHS in recent years, but a tendency remains for commissioners and providers to measure
structures and processes rather than outcomes. [41] Measuring outcomes, though, comes with new
challenges. For example, engaging with patients to identify outcomes that matter to them, and finding
the resources to collect and analyse outcomes, which may occur sometime after clinical contact has
ended require new ways of working.

Equity: Value in the NHS must take account of the inherent tension between individual patient and
population needs. Obtaining value requires being “proportionate”, “fair” and “equitable”. Attaining value
in systems with fixed available resource, therefore, requires judgements about the relative value of
different interventions and technologies and their use across the population. Value-based decisions have
wider social implications: a view supported by NICE, which describes two types of value judgements -
social and scientific. [42]

Value represents a relationship: Value is a relationship between resources, outcomes and

context. Focusing on only one part of this relationship, such as outcomes, will be insufficient to
increase value in the NHS.

What do we mean by value-based healthcare in the NHS?

The value in a universal healthcare system relates the health outcomes and experiences achieved to the
resources used in the context of the services provided and the population served. How we define and
measure value, therefore, varies depending on the context. The emphasis should, therefore, be to define
value-based healthcare and describe its most essential characteristics in a way that is meaningful to
everyone, from individual patients to national organisations, and from prevention to end of life care. We
propose that:
Value-based healthcare is the equitable, sustainable and transparent use of the
available resources to achieve better outcomes and experiences for every person.
“Equitable, sustainable and transparent”
✓ Resources are used to achieve better outcomes and experiences for every individual in the population
in a way that is proportionate and fair. Value-based healthcare takes the wider impact of resource use
and allocation into account, recognising that there are opportunity costs to resource use in the NHS and
that healthcare has an important role to play in reducing health inequalities.
✓ The available resources are used in a way that will not compromise the availability of resources
(financial and environmental) for the future.
✓ Judgements about resource allocation, resource use and about the outcomes and experiences that
NHS organisations prioritise and measure are explicit, open and honest throughout the system.
Transparency in decision making is part of the NHS constitution. The National Institute for Health and
Care Excellence has demonstrated the importance of a transparent approach or “accountability for

8
 Defining Value-based Healthcare in the NHS: CEBM report

reasonableness” in resource allocation decisions [43].

“Use of the available resources”

✓ The allocation and application of the resources that are available to the system, many of which may
not be monetised, are defined and measured.
✓ Decision makers recognise that resource use in itself can be a positive outcome, contributing to, for
example, staff well-being, the wider community and social and physical environments.
✓ The way that resources are allocated and applied is reported in a meaningful way and fed back into
decision-making processes to improve evidence and justify the future investment, or changes to the
investment of resources, including opportunity costs.

“Outcomes and experiences for every person”

✓ Definitions of the most important outcomes and experiences are available for the service being
delivered.
✓ The most important outcomes and experiences for every person are defined by the needs and
preferences of the patients, the public and society using the best available evidence.
✓ Outcomes and experiences are measured, reported in a meaningful way and fed back into decision-
making processes to justify the future investment of resources, including opportunity costs.

2. The key challenges and barriers to value-based healthcare in the NHS

1. Better data: The problems of defining, measuring and sharing data about resource use
(including staff, patient and carer time) and outcomes and experiences that matter to patients
are significant barriers to increasing value. The availability of data and analytical capability to
measure both outcomes and resources offered by NHS organisations is currently limited.

2. Better evidence: Understanding what works to increase value requires better evidence about
what happens in the real world of the NHS, i.e. effectiveness, not efficacy. Knowing what
works provides useful evidence to feed into decision making about resource use and allocation.

3. Describing the Journey to Value: In the absence of whole-scale change, pragmatic

approaches to increase value are happening across the NHS without a clear map. A step by
step guide for programmes to increase value that is flexible to scale and focus would be
helpful.

4. Multi-disciplinary Engagement: Increasing value in practice must be multidisciplinary and

involve all stakeholders, especially including patients. Multiple skills are needed, and many
professional groups must be engaged. But value means different things to different
people/stakeholders, and there are multiple perspectives at any one time.

5. A Value-based culture: There is a need to unify language, culture and behaviour around
value to gain currency in the NHS. Language about value is not socialised at board levels as
‘normal’. There is a common misconception that programmes to increase value are simply
looking for cost-efficiencies. Large-scale action to increase value in the NHS will require
system-wide behaviour change, individual clinical behaviour change and culture change.

6. A Value-based System: The culture of the NHS will need to change dramatically to focus on
delivering value. Financial constraints, performance targets, staff burnout and competing
priorities are identified distractors and barriers to successfully implementing value-based
improvements. The absence of accountability, levers and incentives for value in a system with
a collective “rescue” culture make it challenging to make value a priority.

9
 Defining Value-based Healthcare in the NHS: CEBM report

CASE STUDY: Increasing Value in COPD Care

Aneurin Bevan University Health Board (ABUHB) has an annual budget of £1.1 billion and serves a
population of over 600,000 people in South East Wales. Prevalence rates of Asthma and COPD in this
area are similar to the Welsh average.

What was the value problem?

£17.3 million was spent on respiratory drugs in Gwent in 2014/15, of which £16 million was inhaled
therapy for Asthma and COPD. 65% of this prescribing spend was on Inhaled Corticosteroids (ICS).
Approximately 45% of ICS items were prescribed as high strength products. These patterns of
prescribing appeared to be out of step with national guidelines for the management of Asthma and COPD
and prescribing costs were disproportionately high. ABUHB still had a higher rate of admissions/
procedures for COPD and Asthma than other parts of Wales.

In 2014/15 Respiratory physicians, general practitioners, pharmacists, patients, third sector and finance
colleagues collaborated to examine the available data, identify the main issues, understand the value
problem by considering how resources were distributed across the system and develop solutions.

Between 2014/15 and 2016/17 ABUHB reduced respiratory prescribing spend by £1.3M. The proportion
of high strength Inhaled corticosteroids prescribed decreased from 39% in 2014 to 23% in 2017.

A significant challenge faced by this project was the availability of data to understand the problem and to
demonstrate an improvement in outcomes. For example, it was not possible to distinguish prescribing
related to asthma from prescribing related to COPD and, at the end of the project, proxy indicators were
used to assess outcomes. ABHUB have subsequently begun a programme to systematically measure
patient-reported outcome measures and are now measuring outcomes in about 20 areas. This is only
possible with the patient being central in the design and implementation of the systems which support
the collection of PROMs.

3. Skills and training needed to deliver value-based healthcare

Common challenge Skills and Training Gap

Better data: - The analytical capability to define and measure health outcomes and
experiences with patients in the national and local context.
- The analytical capability to define and measure resource use in the
national and local context.
- Communication skills to disseminate information to NHS managers,
healthcare workers, patients and the public.

Better evidence: - Skills and knowledge to translate existing evidence into programmes
to increase value, and to evaluate programmes designed to increase
value.
- Communication skills to disseminate new evidence from programme
evaluations.

Describing the Journey to - The capacity to identify and prioritise ‘value problems’ (i.e. aspects
Value: of care in which value can be improved).
- Knowledge synthesis to provide a guide to the process of increasing

10
 Defining Value-based Healthcare in the NHS: CEBM report

value that could apply at an organizational level or for smaller systems

of care.

Multi-disciplinary - Training and skills development in value is needed for a range of

Engagement: different professional groups, from directors to managers to clinicians
to finance people.
- Effective communication skills to achieve “buy-in” from patients, the
public and disparate groups of professionals.

A Value-based culture: - Training in value-based healthcare, leadership skills, understanding

culture, behaviour and the process of culture change to increase
value.

A Value-based System - Skills and knowledge in healthcare systems and their role in
increasing value.

Conclusion
Improving health outcomes as a goal in itself is worthy but cannot be achieved at any cost in a health
system with a fixed budget. Managing the use of financial resources is essential in a health service with
budgetary pressures, but cost efficiencies can be misplaced. The relationship between health outcomes
with resource use, resource allocation and context must be understood to make good decisions. A
common language to articulate this relationship is needed, if value-based healthcare is to be embraced in
the NHS. We suggest that value-based healthcare is defined as the equitable, sustainable and
transparent use of the available resources to achieve better outcomes and experiences of
care for every person.

Implementing value-based healthcare will require system change and for new behaviours and culture to
become the norm in the NHS. From on our analysis, we make the following recommendations for patients
and professionals in the NHS who are interested in increasing value at a local or national level:

1. Adopt a common terminology so that every person involved in healthcare, including patients, has
a shared understanding of what value-based healthcare is.
2. Identify and communicate unwarranted variations in healthcare to every person, ensuring
genuine transparency about why value-based healthcare is essenital, and why realistic decisions
based on the available resources are required.
3. Recognize and develop strategies to overcome barriers to implementing value-based healthcare
at the individual, team and organisational level.
4. Build capacity and capability to translate and implement the best available research evidence into
effective action to increase value.
5. Develop the necessary skills in value-based healthcare by training staff in how to measure
outcomes, patient experience and resource use
6. Ensure programmes to increase value are monitored and evaluated to provide better evidence
about what is and isn’t effective
7. Facilitate better communication and dissemination about what works in increasing value at a local
and national level.
The NHS England Long Term Plan, [44] Realistic Medicine in Scotland [30] and Prudent Healthcare [31] in
Wales have all encouraged aspects of value-based healthcare in the NHS. However, value-based
healthcare has yet to achieve the reach of evidence-based healthcare. Developing a common
understanding of the meaning and implications of value-based healthcare, and developing the right skills
and knowledge in the workforce will be essential to implementing it and delivering high-quality affordable
care.

11
 Defining Value-based Healthcare in the NHS: CEBM report

Declaration of interest:

LH is the module coordinator of a Postgraduate course in Healthcare Value, is developing a postgraduate

certificate course in Healthcare Value and is the spouse of the Director of the Evidence-Based Medicine
Datalab, used as a case study in this report. AP received grants from NIHR, from NIHR School for Primary
Care Research, during the conduct of the report and occasionally receives expenses for teaching
Evidence-Based Medicine. SL receives grants and non-financial support from ICHOM, grants from Abbvie,
non-financial support from Janssen and non-financial support from ABHI outside the submitted work. AB
has co-edited a textbook titled: 'Practising Public Health: A Guide to Examinations and Workplace
Application' which includes discussions of principles of public health, such as value. CH has received
expenses and fees for his media work, including BBC Inside Health. He holds grant funding from the
NIHR, the NIHR School of Primary Care Research Evidence Synthesis Working Group (project 390), The
NIHR Oxford BRC, and the WHO. The CEBM jointly runs the EvidenceLive Conference with the BMJ and
the Overdiagnosis Conference with some international partners; these are based on a non-profit model.
CH is Editor in Chief of BMJ Evidence-Based Medicine and an NIHR Senior Investigator Award.

Acknowledgements:

Thanks to the following for participating in the CEBM workshop:

Professor Gwyn Bevan - Emeritus Professor of Policy Analysis, London
School of Economics
Dr John Harvey - Consultant in Public Health, North Staffordshire Clinical
Commissioning Group
Joni Jabbal - Researcher - Policy, The King’s Fund
Julian Marks - PPI Contributor
Professor Jonathan Michie - President, Research Centre Director and Professor of Innovation &
Knowledge Exchange, Kellogg College
Dr Tim Wilson - Managing Director, Oxford Centre for Triple Value Healthcare Ltd and Honorary Fellow,
Nuffield Department of Primary Care Health Sciences, University of Oxford
And to
Sir Professor Muir Gray - Founding Director, Oxford Centre for Triple Value Healthcare Ltd and Visiting
Professor in the Nuffield Department of Surgical Sciences at the University of Oxford
Funding
The meeting was funded by an NIHR Senior Investigator Award to Carl Heneghan. The views expressed
are those of the authors and not necessarily those of the NIHR or the Department of Health and Social

12
 Defining Value-based Healthcare in the NHS: CEBM report

References
1 Sackett DL, Rosenberg WM, Gray JA, et al. Evidence-based medicine: what it is and what it isn’t. BMJ 1996;312:71–2.
2 Haynes RB, Sackett DL et al. Evidence-based medicine: How to practice & teach EBM. Can Med Assoc J 1997;157:788.
3 Gray JAM. Evidence-based health care. Evidence-based Healthcare. 1997;1:1. doi:10.1016/s1462-9410(97)80004-6
4 Gray JAM. Evidence-based healthcare. Elsevier Health Sciences 2001.
5 Overdiagnosis: what it is and what it isn’t. BMJ Evidence-Based Medicine 2018;23:1–3.
6 Heneghan C, Aronson JK, Goldacre B, et al. Transvaginal mesh failure: lessons for regulation of implantable devices. BMJ
2017;359:j5515.
7 Goldacre B, DeVito NJ, Heneghan C, et al. Compliance with requirement to report results on the EU Clinical Trials Register:
cohort study and web resource. BMJ 2018;362:k3218.
8 Kmietowicz Z. WHO downgrades oseltamivir on drugs list after reviewing evidence. BMJ 2017;357:j2841.
9 Croker R, Walker AJ, Bacon S, et al. New mechanism to identify cost savings in English NHS prescribing: minimising ‘price per
unit’, a cross-sectional study. BMJ Open. 2018;8:e019643. doi:10.1136/bmjopen-2017-019643
10 Gray M. Value based healthcare. BMJ 2017;356:j437.
11 EUPIA. The Value of Health: Improving Outcomes Final Report. 2018.https://www.efpia.eu/media/412160/180924-the-value-
of-health-final-report-hi-res-1.pdf
12 Hinsliff G. The NHS is underfunded. Even a former Tory health secretary sees it. The Guardian.
2018.http://www.theguardian.com/commentisfree/2018/apr/03/andrew-lansley-bowel-cancer-nhs-money-screening (accessed
31 Jan 2019).
13 Private firms cash in on over-stretched NHS. BBC. 2018.https://www.bbc.com/news/health-44874238 (accessed 31 Jan 2019).
14 OECD. Tackling Wasteful Spending on Health. OECD Publishing 2017.
15 Wennberg JE. Time to tackle unwarranted variations in practice. BMJ 2011;342:d1513.
16 Mays N. Reducing unwarranted variations in healthcare in the English NHS. BMJ 2011;342:d1849.
17 Watson J, Salisbury C, Jani A, et al. Better value primary care is needed now more than ever. BMJ 2017;359:j4944.
18 Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open 2018;8:e018557.
19 Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012;344:e3502.
20 Moynihan R, Henry D, Moons KGM. Using evidence to combat overdiagnosis and overtreatment: evaluating treatments, tests,
and disease definitions in the time of too much. PLoS Med 2014;11:e1001655.
21 McCartney M. Is the USA’s problem ours too? BMJ 2012;345:e6617.
22 Carter P. Operational productivity and performance in English NHS acute hospitals: unwarranted variations. London:
Department of Health 2016.
23 Curtis HJ, Croker R, Walker AJ, et al. Opioid prescribing trends and geographical variation in England, 1998-2018: a
retrospective database study. Lancet Psychiatry 2019;6:140–50.
24 Walker AJ, Curtis HJ, Bacon S, et al. Trends and variation in Prescribing of Low-Priority Medicines Identified by NHS England:
A Cross-Sectional Study and Interactive Data Tool in English Primary Care. doi:10.1101/211235
25 Croker R, Walker AJ, Goldacre B. Why did some practices not implement new antibiotic prescribing guidelines on urinary tract
infection? A cohort study and survey in NHS England primary care. J Antimicrob Chemother Published Online First: 22
December 2018. doi:10.1093/jac/dky509
26 Public satisfaction with the NHS and social care in 2018. The King’s Fund. 2019.
https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-social-care-2018 (accessed 28 Mar 2019).
27 Ham C. Doctors must lead efforts to reduce waste and variation in practice. BMJ 2013;346:f3668.
28 Arie S. Can we save the NHS by reducing unwarranted variation? BMJ 2017;358:j3952.
29 England NHS. What is NHS Rightcare? 2017.
30 Scotland NHS. Realistic medicine: Chief Medical Officer’s report 2014--2015. 2015. Scotland: Scottish Government
31 Government W. Prudent Healthcare Securing Health and Well-being for Future Generations. 2016.
32 Getting It Right First Time - GIRFT. https://gettingitrightfirsttime.co.uk/ (accessed 28 Mar 2019).
33 RightCare NHS. NHS RightCare » What is NHS RightCare? https://www.england.nhs.uk/rightcare/what-is-nhs-rightcare/
(accessed 28 Mar 2019).
34 Realistic Medicine Scotland. https://www.nhsinform.scot/care-support-and-rights/nhs-services/using-the-nhs/realistic-medicine
(accessed 28 Mar 2019).
35 Hurta DS, Frazee FB. Transponder maintenance mode method. US Patent.
1997.https://patentimages.storage.googleapis.com/d7/29/a5/510d85c78d1c4d/US5686920.pdf (accessed 28 Mar 2019).
36 Schang L, Morton A, DaSilva P, et al. From data to decisions? Exploring how healthcare payers respond to the NHS Atlas of
Variation in Healthcare in England. Health Policy 2014;114:79–87.
37 Dropkin G. RightCare: wrong answers. J Public Health 2018;40:e367–74.
38 Jabbal J, Lewis M. Approaches to Better Value in the NHS: Improving Quality and Cost. 2018.
39 Department of Health. The handbook to the NHS constitution for England. 2009.
40 Porter ME. What is value in health care? NEJM. 2010; 363 (26): 2477--81. Emphasizes the importance of being attached to
the overall patient experience both in surveys and in compensation/job stability
41 Duggall, A. NHS and Public Health Outcomes Frameworks. The Lancet UK Policy Matters. 2011.
http://ukpolicymatters.thelancet.com/policy-summary-nhs-and-public-health-outcomes-frameworks/ (accessed 28 Feb 2019).
42 Rawlins MD, Culyer AJ. National Institute for Clinical Excellence and its value judgments. BMJ 2004;329:224–7.
43 National Institute for Health and Care Excellence. Social Value Judgements: Principles for the Development of NICE Guidance.
London: : National Institute for Health and Care Excellence (NICE) 2016.
44 England NHS. NHS Long Term Plan. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf.
2019.https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf (accessed 19 Jan 2031).

13