Implementing value‐based health care at scale: the NSW experience

To the Editor: We read with interest the article by Koff and Lyons1 and agree that there is a need to develop, implement and evaluate health systems around patient needs and wishes. Implementing value‐based health care is an excellent initiative to address sustainability and patient‐centred care.2 Genuine reform requires a transition away from volume‐based service contracting towards a multidisciplinary approach focused on evidence of improved outcomes.1,2 This would reward doctors and the system for keeping patients healthy and independent in their own homes, with community support, for as long as possible.2

The Leading Better Value Care initiative (2016–2020)1 may be misinterpreted as another set of top‐down policies. It may also have unintended consequences such as reinforcing the silo approach to disease states, diverting finite hospital and local health district resources, such as staff and expertise, to these 13 policy‐driven priority projects.

In our work in perioperative health care, we have identified some concerns. First, the sustainability of our health systems is tested by patients who are frailer, who have chronic diseases, and who present for high risk surgery.1,3,4 Second, these patients have a higher incidence of post‐operative complications3,4 and are more likely to be discharged to a higher care facility, rather than back to their home.4 Third, performing surgery on these patients is associated with higher costs and hospital readmissions.4 Fourth, our research has found that past policy for surgical patients5 has led to today's “wicked problem”; that is, frontline perioperative clinicians and managers are dealing with lack of time, increased demand for precision, fragmentation of care, lack of coordination across an episode of care, bed block, complexity of care, and unclear patient outcome measures. In this context, work is required to empower patients and staff in shared decision making to understand the true complexity of risks and outcomes associated with high risk surgery.

In conclusion, implementing statewide value‐based care is timely and can be transformational. The high risk surgical patient cohort and the staff providing their care are likely to benefit from, and should be included in, this important reform agenda.