Better value primary care is needed now more than ever

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 …