Archie Cochrane's Second E - the creation of Value based Healthcare
Every country on earth is now facing a resource crisis that will not be resolved simply by focusing more on effectiveness; a new paradigm is required - value based healthcare (VBHC). The EU definition of VBHC is now adopted globally, except in the USA which is not committed to universal healthcare. Their the term ‘value’ is the relationship between outcomes and costs for the patients treated which would be classified as efficiency in all other countries, but Archie did not use the term Efficiency in that narrow way. Archie wrote that he was concerned about ‘the optimum use of equipment and personnel ...to cover all these activities I have used the word efficiency’. He was clearly thinking about value, the first person to do so in modern healthcare. The EU definition has four dimensions - personal, allocative, technical and social, and all four are excellently introduced by Archie. Personal value resonates through his description of care in the prisoner of war camp. Allocative value is highlighted in his text on ‘inequalities between diseases... the division of the medical budget amongst all the medical activities’ (p76). Technical value is described in emphasising the need for the ‘optimum use’ of resources for not only problems of treatment but also ‘..screening, diagnosis, place of treatment and length of stay, and, if necessary, rehabilitation’ (p2) and social value in describing the ‘local pride’ that people had for their ‘cottage hospital’ and how this influenced the flow of resources (p34). Effectiveness and Efficiency therefore introduced VBHC fifty years ago! As health services around the world come to understand that they cannot close the gap between demand and resources by ensuring that only effective interventions are offered, there is a huge opportunity for the Collaboration to lead the VBHC paradigm as it led the Evidence Based Healthcare Paradigm. This does not mean doing cost-benefit analyses. It means using the experience and judgement in all the groups to promote stewardship and provide advice on the best use of resources, on value, not just on effectiveness.