Intended for healthcare professionals


Better value primary care is needed now more than ever

BMJ 2017; 359 doi: (Published 10 November 2017) Cite this as: BMJ 2017;359:j4944
  1. Jessica Watson, NIHR doctoral research fellow1,
  2. Chris Salisbury, professor of primary healthcare1,
  3. Anant Jani, honorary research fellow2,
  4. Muir Gray, honorary professor2,
  5. Brian McKinstry, professor of primary care e-health3,
  6. Rebecca Rosen, senior fellow4
  1. 1Centre for Academic Primary Care, University of Bristol, Bristol BS8 2PS, UK
  2. 2Value Based Healthcare Programme, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  3. 3Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
  4. 4Nuffield Trust, London, UK
  1. Correspondence to: J Watson Jessica.Watson{at}

Effective primary care is essential to deliver high value care, but change needs to be driven by evidence based policy and investment, argue Jessica Watson and colleagues

Healthcare systems globally are facing multiple challenges, with ageing populations, increasing chronic disease, rising multimorbidity, and innovative treatments and technologies all leading to rising costs. With finite resources, and an increasing recognition of the potential harms to patients of overdiagnosis and overtreatment,1 it is essential that resources are used optimally. We explore how the value based healthcare framework2 can help decisions about how to allocate resources, and the importance of good evidence not only for patient treatment but for the organisation of health services.23

What do we mean by value in healthcare?

For the past 20 years most of the focus in healthcare has been on quality, safety, efficiency, and cost effectiveness. However, it is increasingly clear that these four factors alone are not sufficient for the 21st century. Care that is apparently high quality, safe, efficient, and cost effective in other circumstances, will decrease value when delivered to the wrong patient at the wrong time. Optimality—defined by Donabedian as “balancing of improvements in health against the cost of such improvement”—is important.4

As healthcare resources are increased the benefits initially increase but then flatten off (fig 1). By contrast, the amount of harm done increases in direct proportion to the investment of resources. Consequently, the net benefit rises with increasing investment until a point of optimality, after which it falls off. It is at this point that high value care is achieved. For example, population level reductions in risk factors for cardiovascular disease have led to large improvements in cardiovascular mortality.5 However expanding indications for treatment to include low risk people with mild hypertension takes us beyond the point of optimality; here evidence of …

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