Creating health care value together: a means to an important end

Using a value co-creation approach to build closer integration between researchers and the “business” of health care can deliver effective health care reform

Australia’s outgoing Chief Scientist Ian Chubb issued a researcher “call to arms” in November 2015, when he identified Australia as the Organisation for Economic Co-operation and Development (OECD) country in which the research and business communities were least likely to engage with each other: “[given] the rhetorical tailwinds blowing over decades … you would have to conclude that we have a very big anchor (our culture) or no sails (our collective will)”.1 This Supplement supports the importance of this link and argues that the mismatch in a nation that does well in research but poorly on translation can be overcome — but only with our collective focus, new approaches to engagement, and a willingness to capitalise on a governmental direction now firmly rooted in innovation.

In 2013, the Strategic Review of Health and Medical Research (the McKeon Review) made 21 recommendations for improving Australia’s research quality and productivity.2 Among them was the bringing together of hospital and community care networks, universities and research organisations “to embed research within the health care system” and “facilitate best-practice translation of research into healthcare practice”.2

Nearly 3 years later, we are yet to see real evidence of more productive researcher and end user partnerships. Unlike in the United Kingdom, where evidence of the impact of community research is a key requirement for funding success, our national research metrics continue to be heavily weighted to international publication performance and nationally competitive grant processes, which disadvantage non-academic chief investigators. Similarly, health services rarely invite relevant academics or end users to bring their evidence or experience to inform and “grow value” around significant service innovation.

Concurrently, the broader community is witnessing significant change in the way value is conceived and created. This includes a shift from the value-chain model, where value is added by different suppliers in a sequential process, to the constellation model, where value is co-produced by different actors in a non-linear set of interactions — as exemplified by the value co-creation concept.3 Value co-creation occurs when organisations, stakeholders, and end users share, combine and renew each other’s resources and abilities throughout the entire journey from design and production to implementation and continuous development.4,5

Value is subjective and varies as a function of the co-creation experiences of consumers and stakeholders.5 Therefore, value goes beyond optimising health outcomes, and can be achieved in different forms — for example, as organisational improvement, as personal achievements and experiences, via satisfied consumers and stakeholders, or by economic or societal gains.6

The value co-creation approach has been successfully demonstrated within many industries, including tourism and commerce (think Expedia, eBay and Amazon), where design processes have been “disrupted” in order to better understand end user expectations, facilitate meaningful dialogue and improve value for all.5 The application of value co-creation in health care involves a paradigm shift across the entire system — incentivising researchers, clinicians, policy makers, consumers, health care organisations and other stakeholders to jointly explore and create better value in health policy, system design and service delivery.7,8

Key stakeholders in health care include government departments, whose job it is to provide frank, impartial, evidence-based advice to government on policies that will improve community outcomes. Consultation and “real” engagement between the policy and research sectors is critical to maximise value, and much current reform policy is concerned with initiatives that emphasise cooperation between different sectors, such as the primary and secondary care sectors, the public and private sectors, and Commonwealth and state funded sectors. Approaches such as integrated care initiatives seek to link different sectors together in a seamless manner. An example is the “beacon” outpatient substitution model, which brings the strengths of hospital and community care delivery together via partnership between general practitioners with special interests and consultants to increase care quality and reduce cost for patients with complex chronic disease.9,10

In undertaking this work, governments bring together key policy levers around funding, legislation and regulation to encourage and drive improvement. All of these rely on healthy cooperation and engagement between different sectors and ideally should operate in an environment of co-creation, including where appropriate, the relevant research community.

Better use of existing health data is also an increasingly recognised area for value creation. Although impressive efforts have already been made, in the form of reports and peer-reviewed articles from the National Health Performance Authority (NHPA), the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the New South Wales Bureau of Health Information, there remains much untapped potential for these data to be used to build value in health service improvement at all levels. Innovative partnerships between consumers, health professionals, policy makers, researchers and data organisations have demonstrated how new knowledge, using techniques to mine big data, reveals where investments to improve care in Australia will yield the highest return. The NHPA has publicly named postcode areas where improvements in immunisation rates would almost certainly prevent sickness, hospitalisation or premature death;11 local areas where avoidable hospitalisations for the treatment of chronic health conditions are at least 10 times higher than in other similar communities;12 and hospitals with the highest rates of serious yet preventable infections.13 The ACSQHC recently identified local communities where rates of antibiotic dispensing were over 11 times higher than in other similar areas, and local areas where 33 000 knee arthroscopies are performed despite evidence the procedure is of limited value for people with osteoarthritis.14 End user partnerships also offer insights into the information needs of consumers of health as they navigate complex systems. To create value, however, information mined from big data must also create a call to action and inform audiences about where the biggest opportunities lie, allowing them collectively to take informed action to change health systems and services.

In 2014, in the MJA Supplement “Building a culture of co-creation in research” (https://www.mja.com.au/journal/2014/201/3/supplement), we shared our experience of using the value co-creation approach with influential research partners and stakeholders. Now, in this Supplement, we explore the use and impact of value co-creation as a driver for health care reform, at a time when systems are reaching to improve value within resource constraints: reporting on the further study of the Primary Care Practice Improvement Tool (PC-PIT) in practice settings, and resulting development of a resource suite to support quality improvement initiatives, and providing perspectives on the evolution of the role of consumer in value co-creation, as well as the experience of using a value co-creation approach in mental health commissioning and polypharmacy reduction research design.

With Australia’s health system under ongoing pressure, due to increasing health complexity, an ageing population and rising rates of chronic disease, we need to maximise user value within tightening fiscal frameworks. A system that integrates and leverages existing opportunities and technology, increases involvement of consumers and all stakeholders, and creates opportunities for increasing innovation, productivity and co-created outcomes of value for end users is key.

What we now need is a clear national direction that locks in a vision for value co-creation at all levels of the health system — establishing ongoing, collaborative design and review as a key role for health services, end users and the research community. Such integration between the researchers and “businesses” of health care might do much to lift our current unenviable OECD ranking, and unlock the innovation for which our nation has been traditionally renowned.