The Glossary is being prepared based on principles from many sources, including the creation of the Oxford English Dictionary. A quote from a document is included when possible, but when no succinct, clear definition can be found in the main OVSP Glossary, which is 250,00 words long. A short definition is created. There is also a longer version of this glossary and a book on the Fundamental Language for creating Value-Based Healthcare , and a book on forty of the key source books, titles the Fundamental Books for understanding Value-Based Healthcare.
However, it is not sufficient to define meaning in words alone. A J Ayer argued in his 1935 book Language, Truth and Logic, written at the age of 24 that the best way to assess the meaning of someone’s proposition such as “this hospital is more efficient than that hospital, and more efficient than it was last year” was to decide if he knows what observations would lead him, under certain conditions, to accept the proposition as being true, or reject it as being false” ie what data should be collected and what information produced. Ludwig Wittgenstein obviously advocated the need for clarity of language, but also emphasised that complex issues could sometimes best be understood by pictures like tables, like the table showing the interrelationships of the four types of value at the top of the page or a Venn diagram.
NHS Frimley has provided resources to identify all the measures that are available for the terms in the glossary, and the data that necessary to produce these measures in a project led by Jane Johnston of APHA and this will, of course inform the preparation of specifications for IT systems and the FDP.
The progress that has been made by 14th October is shown on the linked page.
USING THE GLOSSARY TO CHANGE CULTURE
Words have meanings but the meanings create and change reality as well as expressing it. They change the circuits in the brain , a process sometimes called rewiring and to bring about a paradigm shift the leadership needs to tell people that new circuits are needed, and can be created due to the neuroplasticity of the brain. Of course formal training is essential and the five key skills for the new paradigm of value-based healthcare, mentioned 8 times in the 10 year Plan, and set out below
But it also requires the adoption of a common language, which the military call Doctrine, not only to prevent confusion but also to create a new culture. Language creates social reality and here is the new language for the new reality, namely that everyone has to feel a sense of stewardship for optimising value and minimising waste from the resources available for health and social care.
The leadership of a health service should ensure that everyone in that service understands the terms and uses them consistently
THE DRAFT GLOSSARY
Appropriate, Necessary and, Futile
A treatment is:
Commissioning
Commissioning is the continual process of planning, agreeing and monitoring services. Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment.
NHS website www.england.nhs.uk 14/4/25
Cost-effectiveness, productivity, and efficiency
Culture
“Culture is the shared tacit assumptions of a group that it has learned in coping with external tasks and dealing with internal relationships.”
Schein EH (1999) The Corporate Culture Survival Guide. John Wiley & Sons. Page 186.
Efficacy and Effectiveness
Empathy
Empathy is different from sympathy or compassion.
It is the ability to understand what another is thinking from their perspective and communicate to the other that they have managed to do this -
Howick J et al (2018) Therapuetic Empathy; what it is and what it isn’t. JRSM 111-233-236
Equity, Equality
Integrated care – System, Network and, Pathway
Leadership, Management, & Accountability
Overuse
“Overuse is the provision of medical services for no benefit or for which harms outweigh benefits.”
Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S (2012) Less is more. Overuse of healthcare services in the United States. An understudied problem. Arch Intern Med 172(2): 171-179.
Population health, population healthcare and, population health management
Precision medicine, Stratified medicine and Personalised medicine and healthcare
Programme budgeting and marginal analysis
Programme budgeting, sometimes called service line accounting in industry, is budgeting based not on institutions but on segments of the population defined by need, for example budgets for people with respiratory problems or people in the last year of life. Within a budget for such a segment there may be budgets for sub segments, for example budgets for people with asthma and for people with COPD within the respiratory budget.
Marginal analysis is a technique for estimating the effects shifting resources from the budget for one segment or subsegment budget to another.
Quality
“The quality of a service is the degree to which it conforms to pre-set standards of goodness.” Donabedian A (1980) The definition of quality: a conceptual exploration. In: Explorations in Quality Assessment and Monitoring. Volume 1: The Definition of Quality and Approaches to its Assessment. Health Administration Press, Ann Arbor.
Quality has a number of dimensions including efficiency and safety. Here are the six defined by the Institute of Medicine namely that care should be:
• Timely
• Safe
• Effective
• Patient centred
• Efficient
• Equitable
Quality measures can be used internally for quality improvement or externally for monitoring services
Resilience
Resilience is the ability of a health service to cope with challenges, first described by the World Health Organisation following their analysis of how well health services coped with the Covid Pandemic but relating to all major challenges such as population ageing and the growing need and demand for clinical services when resources are finite.
Shared decision-making
“In a shared decision, a health care provider communicates to the patient personalized information about the options, outcomes, probabilities, and scientific uncertainties of available treatment options, and the patient communicates his or her values and the relative importance he or she places on benefits and harms.”
Wennberg JE (2010) Tracking Medicine. A Researcher’s Quest to Understand Health Care. Oxford University Press.
It is also important to ensure that the benefits and harms of doing nothing be fully explored
Stewardship
“Stewardship is to hold something in trust for another.”
Block P (1996) Stewardship: choosing service over self-interest. Berrett-Koehler.
Stewardship is a culture in which people who do not own something are committed to ensuring its survival for future generations.
Structure, Process and, Outcome
Outcomes that matter to health and social care
These outcomes are the results of health and social care interventions that indicate that high value is being realised for individuals and populations.
Outcomes that matter to individuals
These outcomes are the results people care about most and they often differ from the outcomes regarded as important by clinicians and people who manage health services. ICHOM has produced very good sets of outcomes https://www.ichom.org/about-ichom-sets/)
Strategy
A strategy is a coherent collection of actions that has a reasoned chance of improving results.
Friedman, M. (2005) Trying Hard is not Enough. How to Produce Measurable Improvements for Customers and Communities. Trafford Publishing. (p. 20).
The Military distinguish clearly between strategic, operational and tactical decision making
Value
Value is assessed by weighing up the benefits received by an individual or a group if people with a common need or by a population, considering the resources that have been used. It is essential to measure outcomes and to use the population as the denominator as well as the number of patients treated because.
The EU defined four perspectives on value, one of which, personal value is of vital importance in assessing the other three perspectives
Variation, Warranted and Unwarranted
Waste is the use of resources that would produce more value if used for another purpose or another subgroup of the population. There are four types of waste in healthcare:
Waste left after a job has been done.
Wellbeing
There is no single definition of the term health except the WHO definition that it is that it is more than the absence of disease. For this reason the term wellbeing is increasingly used in part because there are a number of criteria that can be used to measure wellbeing
By wellbeing we mean, how do you feel about your life, how satisfied you are.We do not mean external circumstances that affect your wellbeing. We mean the thing that ultimately matters :your inner subjective state – the quality of your life as you experience it , how happy you are
How should we measure it ?
However, it is not sufficient to define meaning in words alone. A J Ayer argued in his 1935 book Language, Truth and Logic, written at the age of 24 that the best way to assess the meaning of someone’s proposition such as “this hospital is more efficient than that hospital, and more efficient than it was last year” was to decide if he knows what observations would lead him, under certain conditions, to accept the proposition as being true, or reject it as being false” ie what data should be collected and what information produced. Ludwig Wittgenstein obviously advocated the need for clarity of language, but also emphasised that complex issues could sometimes best be understood by pictures like tables, like the table showing the interrelationships of the four types of value at the top of the page or a Venn diagram.
NHS Frimley has provided resources to identify all the measures that are available for the terms in the glossary, and the data that necessary to produce these measures in a project led by Jane Johnston of APHA and this will, of course inform the preparation of specifications for IT systems and the FDP.
The progress that has been made by 14th October is shown on the linked page.
USING THE GLOSSARY TO CHANGE CULTURE
Words have meanings but the meanings create and change reality as well as expressing it. They change the circuits in the brain , a process sometimes called rewiring and to bring about a paradigm shift the leadership needs to tell people that new circuits are needed, and can be created due to the neuroplasticity of the brain. Of course formal training is essential and the five key skills for the new paradigm of value-based healthcare, mentioned 8 times in the 10 year Plan, and set out below
- Ensuring the survival of universal healthcare by increasing value and reducing waste;
- Shifting the focus from bureaucracies to populations ;
- Developing population based systems and delivering care through networks ;
- Creating a culture of stewardship;
- Optimizing personal value
But it also requires the adoption of a common language, which the military call Doctrine, not only to prevent confusion but also to create a new culture. Language creates social reality and here is the new language for the new reality, namely that everyone has to feel a sense of stewardship for optimising value and minimising waste from the resources available for health and social care.
The leadership of a health service should ensure that everyone in that service understands the terms and uses them consistently
THE DRAFT GLOSSARY
Appropriate, Necessary and, Futile
A treatment is:
- Necessary, if there is general clinical agreement that it is essential, even though there is a risk.
- Appropriate, if the majority of the clinical community agrees the benefits outweigh the risks and that the intervention is justified.
- Inappropriate, if the majority of the clinical community agrees that the risks outweigh the benefits and that its use is not justified
- Futile, if the clinical community agrees the intervention would do more harm than good.
Commissioning
Commissioning is the continual process of planning, agreeing and monitoring services. Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment.
NHS website www.england.nhs.uk 14/4/25
Cost-effectiveness, productivity, and efficiency
- Productivity relates the outputs of a service to the inputs.
- Efficiency relates the outcomes of care to the inputs, namely the resources used for that group of patients; this is the meaning of Value as used in the USA
- Cost-effectiveness relates the outcomes of a technology or intervention to the costs
Culture
“Culture is the shared tacit assumptions of a group that it has learned in coping with external tasks and dealing with internal relationships.”
Schein EH (1999) The Corporate Culture Survival Guide. John Wiley & Sons. Page 186.
Efficacy and Effectiveness
- Efficacy is the magnitude of the benefit demonstrated in the research setting.
- Effectiveness is the degree to which an intervention whose efficacy has been proven in the research setting delivers benefit in the ordinary service setting.
Empathy
Empathy is different from sympathy or compassion.
It is the ability to understand what another is thinking from their perspective and communicate to the other that they have managed to do this -
Howick J et al (2018) Therapuetic Empathy; what it is and what it isn’t. JRSM 111-233-236
Equity, Equality
- Inequality is an objective difference in mortality, morbidity, or service provision.
- Inequity is a difference in service access for people in the more deprived sections of the population or in some ethnic groups, and these two characteristics often occur together .
Integrated care – System, Network and, Pathway
- A network is a set of organisations and individuals that deliver the system’s objectives.
- A system is a set of activities with a common aim, a common set of objectives, and a set of criteria against which progress towards the outcomes that matter can be measured. A population-based system is often called an ACO an Accountable Care Organisation
- A pathway is the course an individual follows as they go through the system.
Leadership, Management, & Accountability
- Leadership creates and changes culture.
- Management achieves the objectives of an organisation working within that culture.
- Accountability is a relationship based on the provision of information about performance from those who have it to those who have a right to it.
Overuse
“Overuse is the provision of medical services for no benefit or for which harms outweigh benefits.”
Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S (2012) Less is more. Overuse of healthcare services in the United States. An understudied problem. Arch Intern Med 172(2): 171-179.
Population health, population healthcare and, population health management
- Population health means the health status of a defined group of people.
- Population healthcare focuses primarily on segments of the whole population defined by a common need which may be a symptom such as breathlessness, a condition such as
- Population health management was originally a method which stratified the population by levels of risk, allowing resources to be focused on those subgroups at highest risk although it is now used more broadly and PHM and Population healthcare can be regarded as synonyms
Precision medicine, Stratified medicine and Personalised medicine and healthcare
- Personalised medicine considers a person's unique clinical characteristics and aligns evidence based treatment choices to those characteristics Personalised care considers a person's goals, beliefs, values and preferences and supports them to decide on a course of action that is most likely to lead to them attaining their goals. In the context of healthcare delivery, a preference is a course of action that is informed by a person's values (and by their knowledge of the benefits and harms of the options they face) and that maximises individual health gain by helping them move towards their life goals
- Precision medicine uses the patient’s biomarkers in addition to other clinical measures such as blood pressure.
- Stratified medicine focuses on the person’s level of risk, considering their genetic profile as well as their clinical condition.
Programme budgeting and marginal analysis
Programme budgeting, sometimes called service line accounting in industry, is budgeting based not on institutions but on segments of the population defined by need, for example budgets for people with respiratory problems or people in the last year of life. Within a budget for such a segment there may be budgets for sub segments, for example budgets for people with asthma and for people with COPD within the respiratory budget.
Marginal analysis is a technique for estimating the effects shifting resources from the budget for one segment or subsegment budget to another.
Quality
“The quality of a service is the degree to which it conforms to pre-set standards of goodness.” Donabedian A (1980) The definition of quality: a conceptual exploration. In: Explorations in Quality Assessment and Monitoring. Volume 1: The Definition of Quality and Approaches to its Assessment. Health Administration Press, Ann Arbor.
Quality has a number of dimensions including efficiency and safety. Here are the six defined by the Institute of Medicine namely that care should be:
• Timely
• Safe
• Effective
• Patient centred
• Efficient
• Equitable
Quality measures can be used internally for quality improvement or externally for monitoring services
Resilience
Resilience is the ability of a health service to cope with challenges, first described by the World Health Organisation following their analysis of how well health services coped with the Covid Pandemic but relating to all major challenges such as population ageing and the growing need and demand for clinical services when resources are finite.
Shared decision-making
“In a shared decision, a health care provider communicates to the patient personalized information about the options, outcomes, probabilities, and scientific uncertainties of available treatment options, and the patient communicates his or her values and the relative importance he or she places on benefits and harms.”
Wennberg JE (2010) Tracking Medicine. A Researcher’s Quest to Understand Health Care. Oxford University Press.
It is also important to ensure that the benefits and harms of doing nothing be fully explored
Stewardship
“Stewardship is to hold something in trust for another.”
Block P (1996) Stewardship: choosing service over self-interest. Berrett-Koehler.
Stewardship is a culture in which people who do not own something are committed to ensuring its survival for future generations.
Structure, Process and, Outcome
- The structure is the organisation which may be a bureaucracy or a market or a network.
- The process is the activities, for example the number of operations done.
- The outcome is the result of the process.
Outcomes that matter to health and social care
These outcomes are the results of health and social care interventions that indicate that high value is being realised for individuals and populations.
Outcomes that matter to individuals
These outcomes are the results people care about most and they often differ from the outcomes regarded as important by clinicians and people who manage health services. ICHOM has produced very good sets of outcomes https://www.ichom.org/about-ichom-sets/)
Strategy
A strategy is a coherent collection of actions that has a reasoned chance of improving results.
Friedman, M. (2005) Trying Hard is not Enough. How to Produce Measurable Improvements for Customers and Communities. Trafford Publishing. (p. 20).
The Military distinguish clearly between strategic, operational and tactical decision making
Value
Value is assessed by weighing up the benefits received by an individual or a group if people with a common need or by a population, considering the resources that have been used. It is essential to measure outcomes and to use the population as the denominator as well as the number of patients treated because.
The EU defined four perspectives on value, one of which, personal value is of vital importance in assessing the other three perspectives
- Personal value - appropriate care to achieve a patient’s personal goals
- Technical value - achievement of best possible outcomes with available resources; it is important to emphasise that this means using the resources for all the people in need in the population not just those who reach the service and become patients, for example focusing on all the people in with hip pain, not just those people who have had a hip replacement. This means that technical value also includes measurement and minimisation of inequity
- Allocative value - equitable resource distribution across all populations and within each population across all patient groups
- Social value - contribution of healthcare to social participation and connectedness
Variation, Warranted and Unwarranted
- Warranted Variation is variation in spend or provision of services that can be explained by differences in the populations served, for example differences in spend and activity on haemoglobinopathies in Cornwall and London is warranted variation
- Unwarranted Variation is, to quote the person who created the concept “Variation in the utilization of health care services that cannot be explained by variation in patient illness or patient preferences” Wennberg JE (2010) Tracking Medicine. A Researcher’s Quest to Understand Health Care. Oxford University Press. The importance of the publication of unwarranted variation, firstly in the Dartmouth Atlas of Health Care and then in the NHS Atlases is that it forces people to ask
- If I am in the upper end of the range is that right for my population or could it be overuse and waste?
- If I am in the lower end of the range is that right for my population or could it be underuse of high value healthcare and an indication of possible inequity?
Waste is the use of resources that would produce more value if used for another purpose or another subgroup of the population. There are four types of waste in healthcare:
Waste left after a job has been done.
- Waste due to inefficiency.
- Waste when the resources used do not achieve outcomes that matter to patients.
- Waste due to opportunity costs, namely when those resources could have provided greater value when used for another purpose for people with a defined health problem or reallocated for use for people with another type of health problem.
Wellbeing
There is no single definition of the term health except the WHO definition that it is that it is more than the absence of disease. For this reason the term wellbeing is increasingly used in part because there are a number of criteria that can be used to measure wellbeing
By wellbeing we mean, how do you feel about your life, how satisfied you are.We do not mean external circumstances that affect your wellbeing. We mean the thing that ultimately matters :your inner subjective state – the quality of your life as you experience it , how happy you are
How should we measure it ?
- Evaluative measures; life satisfaction approach, on a scale from 0 to10
- Hedonic measures based on ‘affect’
- Eudamonic measures…’do you feel that the things that you do in your life are worthwhile