Maximising Value in Healthcare Systems by Putting the Patient at the Centre – Systemic Design Considerations

ABSTRACT

Value‐based healthcare addresses inefficiencies, rising costs, and inconsistent quality by prioritising patient outcomes relative to costs. Despite broad support, its definition and implementation remain unclear. This perspective proposes a systemic, person‐centred approach that aligns stakeholders around shared values. We examine frameworks like Berwick's ‘Triple Aim’ and Porter's patient‐centred model, and integrat Sir Muir Gray's moral dimension for a holistic perspective. Achieving an effective system requires committed leadership, bottom‐up redesign integrating all care levels, and cross‐sector collaboration to align policies with sustainable health improvements. Context‐sensitive metrics are essential to balancing patient‐centred and economic value.

Value‐based healthcare originated from a growing concern about inefficiencies, rising costs, and varying quality in traditional healthcare systems. While there is a general agreement that health systems need to embrace value, it is much less clear what is meant by ‘value’, and how any value proposition might pragmatically impact health system design and sustainability, care delivery, and patient outcomes.

Achieving pragmatic change requires clarity – about the notion of value and the purpose of the health system. Here we outline a systemic approach to developing a values‐based person‐centred health system as we believe that the patient's needs (not wants – which may also be provider driven like indication creep, disease mongering) should be the system's design focus.

1. Values and Purpose – Are They in the Eye of the Beholder?

A review of value definitions identified two broad understandings of values – a business and economics frame referring to efficiencies in terms of return on investment and profit, the other a humanistic frame entailing notions of intrinsic attributes of autonomy, authenticity, benevolence, respect, and resilience as well as a social attributes of collaboration, commitment, equity, resilience, respect and sustainability [1].

Purpose provides a focal point that allows organisations to maintain dynamic stability in a constantly changing environment. However, purpose is often lost when an organisation gets larger and must divide into functional units that typically have their own perceptions on what the organisation values and what their work should achieve.

It is important to recognise the dynamic interdependencies between values and purpose, and thus the need to make both clear to all its stakeholders – in the healthcare context it is patients, providers, suppliers and policy leaders.

2. Current Value‐Based Healthcare Frames

Berwick introduced the term triple aim to define value‐based healthcare – focus on improving patient experience, population health, and reducing costs [2]. He clearly highlighted the interdependencies between these domains, thus implying the systemic nature of ‘value in healthcare’ (Box 1). Berwick believes that we have the knowledge required to build value‐based health systems but that its realisation depends on political will.

Box 1. Berwick's implied system components.

Domain Issues	Implied Focus
Triple Aim Framework: improving patient experience, population health, and reducing costs	System as‐a‐whole
Patient‐Centred Care: aligning care with patient needs and preferences	Patient at the centre of the system
Quality and Safety: reduce waste, improve care quality, and eliminate medical errors	Business
CMS Leadership: value‐based purchasing, accountable care organisations (ACOs), and bundled payments	Leadership
Health Equity Advocacy: the need for healthcare systems to address disparities and promote equitable access to care	System and ethics

Porter emphasised that value in healthcare “should always be defined around the customer [emphasis added], and in a well‐functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system”. He further elaborates that “Value is defined as outcomes relative to costs, it encompasses efficiency”. However, he also cautioned that Cost reduction without regard to the outcomes achieved is dangerous and self‐defeating, leading to false “savings” and potentially limiting effective care" [3].

His notion of value has been translated algorithmically to

$$\underset{(\text{value})}{\mathbf{V}}=\frac{\underset{(\text{quality})}{\mathbf{Q}}+\underset{(\text{service})}{\mathbf{S}}}{\underset{(\text{cost})}{\mathbf{\$}}}$$

which allowed a skewing of value in healthcare to largely focus on costs and cost reduction as cost and value are interchangeable.

$$\underset{(\text{cost})}{\mathbf{\$}}=\frac{\underset{(\text{quality})}{\mathbf{Q}}+\underset{(\text{service})}{\mathbf{S}}}{\underset{(\text{value})}{\mathbf{V}}}$$

As Porter was aware and as others have pointed out [4, 5, 6], operationalising this definition of value is problematic as it is contingent on defining and measuring quality as well as service, besides of agreeing what should be ‘valued’ for whom and for what [3]. Measures clearly matter, but more importantly, we need to measure what matters [7, 8].

$$\underset{(\text{quality})}{\mathbf{Q}}=\underset{(\text{value})}{\mathbf{V}}\ast \underset{(\text{cost})}{\mathbf{\$}}‐\underset{(\text{service})}{\mathbf{S}}$$

There is an even more fundamental problem inherent in this formula, namely the relationship between cost and value; again, as Reinhardt noted, “the value of a “thing” has nothing whatsoever to do with the cost of its production” [9]. However, Porter's approach has been implemented achieving measurable improvements in efficiency and quality in specific healthcare contexts (Box 2).

Box 2. Value‐based healthcare models [10, 11].

Aims	The proclaimed benefits of value‐based healthcare Improved patient outcomes Enhanced patient satisfaction Reduced healthcare costs
Approaches	Financial incentives Providers reimbursed for optimal patient health Team based approaches Focus on wellness and prevention to avert costly interventions in the future
Models	Accountable care organisations (ACOs) groups of providers coordinate care to ensure that patients receive the care they need prevent unnecessary tests and procedures Bundled payment programmes provide a single payment that covers all services provided to a patient, with THE ONE provider who assumes responsibility for all the other providers involved in a single course of treatment. Patient‐Centred Medical Homes (PCHM) A medical home (primary care centre) coordinates care across all providers to make services more accessible through shorter waiting times, expanded in‐person hours, and 24/7 digital access to care team members

A third perspective on value is provided by Sir Muir Gray: “The best shorthand definition of value is to describe it as the relationship between outcome and cost, expressed as the net health benefit – the difference between benefit and harm, taking into account the resources used” [12]. This definition goes beyond the economist's value understanding to include a moral/social/humanistic dimension of equal importance, and is a segway to a systemic understanding of value, health care, and healthcare systems (Box 3).

Box 3. NHS England rightcare programme [13].

The Aim is triple value & greater equity Allocative value, determined by how the assets are distributed to different subgroups in the population Technical value, determined by how well resources are used for all the people in need in the population Personalised value, determined by how well the decisions relate to the values of each individual Personalised service for all the people affected in the population Improvement through collaborative systems and networks with patients & carers as equal partners Transformation by culture change & digital knowledge services Clinicians feel they are the stewards of the population's resources

3. Values and Purpose Are ‘Build‐In’ System Properties

Values and purpose are tightly liked. While purpose focuses everyone's work, shared values are pivotal to achieve a seamlessly integrated system. They become the organisation's core values – those that remain unchanged in an ever‐changing external environment. They form the basis for solving emerging problems and conflicts [14].

Adherence to values and maintaining a focus on the organisation's purpose require a common language, they are paramount to improve everyone's function, and thereby improve the organisation as‐a‐whole [15].

4. Language Matters

How we talk about things reflects how we understand and think about them. This is no better illustrated than in terms of the people we look after – are they ‘patients’, meaning ‘vulnerables’ we have to care for, or ‘customers/clients’ with whom we have a commercial relationship and therefore an obligation to satisfy their ‘wants’?

Our Hippocratic Oath compels us to adhere to medicine's core tenet – primum non nocere, first do no harm. Our first obligation is to attend to our patients’ needs rather than wants, and do so in a collaborative way, or as William Mayo put it in 1910, “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary” [16]. He passionately conveyed his conviction that providing the best possible care requires a systemic approach.

Equally one needs to distinguish the differences between ‘health care’ and ‘healthcare’. ‘Health care’ is an activity, providing care, whereas ‘healthcare’ refers to the place or the system that provides and/or organises care.

Maximising value in healthcare systems requires a system redesign [14] that – at every system level – considers the patient and her care needs as the driver of actions and planning. How can it be done?

5. Value as the System Driver

While values and purpose are tightly linked, the purpose of a system is the key determinant, not only of the system structure but also its values, which together shape its dynamics [14]. If we truly value ‘meeting the patient's care needs’ [14, 17] which go beyond the limits of a disease‐specific effort [18], all stakeholders in the healthcare system must align their aspirations and actions accordingly. For example, in Norway and Sweden, purpose is determined jointly by parliament, the medical profession and patient representatives and scrutinised by a critical population [6]. At a local health service level, the Alaska Native and American Indian people defined the values of their health system which resulted in the ‘NUKA system of Care’ [19].

5.1. What Are the Things, Patients Value?

There are three universal domains that patients really value about health care, summarised as – a shared relationship with their primary care provider, being treated with courtesy, respect, and cultural understanding, and having access to care when needed [19]. It is the basis for achieving a healing relationship with their care providers [20]. Healing relationships, besides of requiring clinical competence, depend on personal attributes that shape the care process – being nonjudgemental, appreciating power differences, and being accessible over the long‐term [20].

5.2. Meeting Values Is Contextual

The needs of patients go beyond the complaint and the biomedical of their diseases. Meeting their care needs requires consideration of their educational, working, housing, nutrition, and social circumstances as well as their community conditions. In other words, it requires systemic thinking and systemic design.

6. Value‐Based Health System Design

A successful value‐based health system requires leadership committed to upholding core values and a clear purpose within their organisation. When leadership prioritises these principles, it enables all stakeholders in the health system to adapt collaboratively, working toward mutually beneficial solutions to satisfy their respective priorities. This approach encourages a shift from a ‘winner‐takes‐all’ mindset to one of mutual benefit and compromise, fostering a ‘give‐and‐take’ attitude among all involved. By emphasising shared values and purpose, leaders can create an environment that supports long‐term, sustainable improvements that align with the needs of the entire health system (Box 4). These improvements may vary significantly depending on the unique needs and constraints arising in different local contexts (a phaenomenon known as mutually agreeable solutions).

Box 4. Systemic design principles.

Pragmatic Redesign Principles of a Patient‐Centred Health Care System The patient needs – not wants – are at the centre Like a vortex all other activities of the system arise from a focal point – the needs of the patient What needs to occur at the doctor‐patient care level What needs to occur at the community level What needs to occur at the regional/national level What needs to occur at the policy/leadership/governance level What is the context of patient/community/national levels How does context influence the relationships and dynamics within and across organisational levels What are the vested interests influencing the various levels

6.1. We Need to See the Entire System

Viewing an organisation as a vortex provides a helpful metaphor for understanding complex adaptive systems. This analogy emphasises the importance of purpose as the organisation's focal point as much as its functional organisational layering. Just as a vortex grows from the bottom up, an organisation similarly relies on continuous bottom‐up feedback. This feedback enables higher levels to provide the required information and constraints that maintain and reinforce its purpose and goals. By fostering a dynamic interchange across levels, the vortex model underscores how each layer contributes to a unified, purpose‐driven system that adapts effectively to evolving needs [1] (Figure 1).

Figure 1.

The Systemic Implications of Value Driving the Health System. Centreing the health system around the core value of ‘meeting the person's needs’ aligns the efforts of all stakeholders, fostering a win‐win‐win outcome: enhanced service delivery and quality of care, reduced costs, and increased value for the system as‐a‐whole. By focusing on patient‐centred needs, each level of care can contribute effectively and efficiently ensuring equity and sustainability.

6.2. Building a Values‐Based Healthcare System From the Bottom‐Up – It Starts With Thinking Differently

A values‐based healthcare system needs a system as‐a‐whole configuration. It requires a bottom‐up approach that aligns patients' three key needs – a shared relationship with their primary care provider, a workforce that treats patients with courtesy, respect, and cultural understanding, and having ready access to care when needed.

The foundational layers of a healthcare system consist of primary, secondary and tertiary care within a community context, supporting both medical and social care needs. Together their providers are best positioned to advocate for community development initiatives that promote health‐enabling environments, including safe housing, quality education, safe and secure work, nutritious food, and safety accessible exercise and recreational spaces.

Above the community level, the focus shifts to system resourcing – building healthcare centres, hospitals and other infrastructure, medical supply chains, medications and medical devices, as well as workforce education to ensure quality health and social care.

The top‐level of the system provides overall system leadership, developing interconnected policies, and ensuring alignment across the system as‐a‐whole. This level also monitors adherence to governance based on shared values and purpose, ensuring a unified, purpose‐driven approach throughout the healthcare system.

6.3. Guiding the Implementation Process

The Committee on Improving the Quality of Health Care Globally [17] has provided a useful guide for enhancing quality of health services (Box 4). Although the recommendations are framed within a systems thinking frame, they have a strong process focus. However, as experience has shown, enforcing specific disease‐management processes can be challenging. ‘Failure’ to adhere to standardised processes arise from local circumstances, the fact that many patients have other morbidities impeding care delivery, and differences in patients' expectations, priorities, and personal capabilities.

Insights from the organisational change management literature suggest that improvement arises from focusing on the organisation's purpose. Thus, translating the principles into locally adapted operating principles, or ‘simple/how to rules’, requires deliberation amongst all stakeholders (Box 5). While this process can be tedious, it has been shown to be the most effective way to achieve ‘buy‐in’ that leads to improved performance and outcomes for organisations [14].

Box 5. From principles to operating principles – guiding adaptive care delivery.

Principles to Guide Health Care [17] …	… to Guide the Development of Locally Adapted Operating Principles (or “Simple Rules”) [14]
Meta Principles: Core Beliefs and Values Systems thinking drives the transformation and continual improvement of care delivery. Care delivery prioritises the needs of patients, health care staff, and the larger community. Decision making is evidence based and context specific. Trade‐offs in health care reflect societal values and priorities. Content Principles: Core Characteristics of High‐Performing Care Delivery Care is integrated and coordinated across the patient journey. Care makes optimal use of technologies to be anticipatory and predictive at all system levels. Leadership, policy, culture, and incentives are aligned at all system levels to achieve quality aims, and to promote integrity, stewardship, and accountability. Navigating the care delivery system is transparent and easy. Problems are addressed at the source, and patients and health care staff are empowered to solve them. Process Principles: Core Processes for Transforming Care Delivery Patients and health care staff codesign the transformation of care delivery and engage together in continual improvement. The transformation of care delivery is driven by continuous feedback, learning, and improvement. The transformation of care delivery is a multidisciplinary process with adequate resources and support. The transformation of care delivery is supported by invested leaders.	Developing operating principles (“simple rules” or “how to rules”) is a deliberative process, they must emerge from within the local setting and CANNOT be PRESCRIBED.
	Operating principles provide “guidance” for decision‐making to all stakeholders regardless of their place and role in the health system.
	Suggested operating principles to achieve a value‐based health system might be: Develop ongoing trustful patient relationships Understand the patient's experiences, needs, and preferences Enhance peoples' capabilities to manage their own health Explore with patients and their families the impact of treatments on their future health Engage with the community to build a local health promoting environment

Note: Adaptive organisations focus on their purpose, goals, and values as the basis for collectively deliberating their operational (or “simple/how to”) rules which guide their internal interactions and exchanges with their external stakeholders. The suggested “simple rules” solely serve as an illustration, and should not be seen as prescriptive.

6.4. Specific Design Considerations for Each System Layer

6.4.1. The Care Delivery Layers

The care delivery layers in a healthcare system must work in an interconnected and interdependent way, ideally by being physically colocated. When providers know each other, share insights, and communicate with each other about obstacles and achievements, the care process becomes highly adaptive, effective and efficient.

Primary care providers, with their deep knowledge of each patient's personal circumstances and the broader environmental factors affecting their health, are essential to informed decision‐making. By working collaboratively with community care, as well as secondary and tertiary care providers, they can make clinical and social decisions that truly reflect each patient's priorities and preferences. This approach embodies ‘best evidence‐based medicine’ as defined by Sackett [21], ensuring that the care delivered aligns with the latest evidence while being personalised to each individual's unique needs and context.

6.4.2. The Community Layer

Strengthening communities is key to good health [22]. This involves the built environment [23] as much as increasing community resources, as outlined in the WHO Ottawa Charter [24]. Health services play a critical role in engaging with local institutions, advocating for necessary developments that reflect the needs expressed by their patients.

The health and social care sector's advocacy role extend to guide advancements in medication and medical devices developments, with a particular emphasis on those conditions that lead to high rates of premature mortality, e.g. malaria, or disability, e.g. diabetes or chronic respiratory diseases.

Of equal importance are their inputs into workforce development and education. The system not only must educate a sufficient number of the various care professionals, it must also ensure that they have the required ‘practical skills’ to attend to individual and community needs.

6.4.3. The Policy and Governance Level

Organisational systems demand leadership and governance that aligns and maintains everyone's focus on what matters – achieving shared goals and values. This entails developing system‐based , rather than issue‐based, policies that enable the simultaneous improvements of all stakeholders. It requires leaders to adopt a mental frame that views every organisational problem as a system problem – in other words making every problem a ‘we’ problem that requires a ‘we‐informed’ solution [25, 26, 27].

A critical role of leadership at an organisation's top level is monitoring system feedback – in particular, where and HOW do the dynamics lead to undesirable developments that hinder the achievements of the system or violate its values.

6.5. Translating Value Understanding Into Action

Although many organisations develop value(s) statements, these generally lack a systems focus. Frequently, such statements are intrinsic and resemble broad, aspirational declarations – sometimes referred to as ‘motherhood statements’ – that fail to provide members with clear guidance to shape their work. In other cases, value statements are deliberately crafted as marketing or sales tools, reflecting a narrow, one‐sided understanding of value (Figure 2). For value statements to drive meaningful action, they must be, as outlined above, thoughtfully designed to align with the organisation's purpose and genuinely able to guide behaviours across the system.

Figure 2.

Contrasting value propositions.

7. The Need to Measure Value‐Based Performance

The design of a value‐based health system must include ‘achievement criteria’ that capture meaningful measures of success [7]. As Drucker suggested, we must distinguish between doing things right – the instrumental dimension, and doing the right thing – the value dimension [28]. Systemic approaches to value‐based performance must assess inputs – such as resource availability; outputs and outcomes – ensuring care is delivered effectively, efficiently, and equitably; and most importantly, whether the care provided aligns with the values defined by recipients [7].

While, as Einstein already noted, “not everything that matters [i.e., we value] can be measured”, it is nevertheless essential to acknowledge these intangible values explicitly. Or, as Deming pointed out, it is misguided to assume that anything not measurable cannot be managed effectively [29].

All measures should reflect the health system's ‘systemic performance’, hence all measures must always be interpreted within the constraints of the local context, accounting for patient and population health needs, geographic challenges, and socioeconomic conditions. This contextualised approach ensures that metrics align with the health and well‐being of individuals and communities served.

8. Facilitating Change – The Need to Focus on Enabling Constraints

The push toward a ‘value‐based health system’ began nearly 30 years ago, yet progress has been slow. Success hinges on a focused effort to strengthen ‘enabling constraints’ across technical, medical, and societal domains. This requires leadership to address three core issues – first, organisations must move beyond fragmented, function‐based structures and the associated top‐down, command‐and‐control leadership. Second, effective change demands leadership that unites members around shared values and purpose, embracing the interconnected and interdependent nature of the health system. Leaders should also view failures as learning opportunities, harnessing the ‘wisdom of the crowd’ and leveraging the insights of all staff. Lastly, the system must adopt a new economic perspective. Economist Mariana Mazzucato has highlighted that economies should prioritise health and well‐being, suggesting that governments position these as central to their economic policy [30]. Aligning health and economic priorities is both feasible and beneficial.

9. Conclusions

Value‐based healthcare aims to address inefficiencies and improve outcomes by focusing on patient needs and aligning healthcare systems around shared values and purpose. By integrating economic and humanistic perspectives, it seeks to enhance efficiency while ensuring patient‐centred care. Successful implementation requires committed leadership, systemic redesign, and context‐sensitive performance measurement, ultimately fostering sustainable improvements in patient and community health.

Author Contributions

Joachim Sturmberg wrote the first draft, and Joachim Sturmberg and Saadi Taher discussed and developed the systemic nature of value‐based health care. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.