Meet the Better Healthcare with No More Money

How can we meet increasing need & demand with no more money?

Clinical advances of the last fifty years have led to dramatic increases in life expectancy and years of life free from disability. However, every health service still faces five outstanding problems and four new challenges that are interlinked: 

Better Value Healthcare has solutions 

Better Value Healthcare (BVHC) is a solutions company, which manufactures resources to solve problems, meet challenges and engage the drivers of change.

BVHC recognizes that the the problems facing health services cannot by solved by money (even if this were an option) or by reorganising the bureaucracy of healthcare.  They can, however, be solved by good leadership and harnessing the drivers for change, which will transform the square peg of 20th century healthcare into a service that fits with the needs of the 21st century.  A new paradigm is needed …
A revolution NOT a re-organisation!

BVHC’s resources can transform your health service while directly addressing your most pressing problems.  Our solutions will help to address different aspects of the problems all health services face.

The Mission of the Surgical Leadership Academy

The mission of the Surgical Leadership Academy is to help surgeons become even better leaders 

In England alone there are about two thousand surgeons in management and leadership positions in addition many young surgeons see the need to develop understanding of management and leadership to prepare them for the health service or academic jobs.

The distinction, and relationship, between management and leadership is now generally agreed with leaders shaping and changing culture whereas managers work within the culture of the organisation. Almost all leaders are also managers but not all managers are part of leadership. Both activities are of vital importance for delivering high quality, safe and high value service to both individual patients and populations.

The principle of the Institute should be for action learning and people to bring problems either at face to face meetings or, increasingly, on-line action learning programmes. There are a very wide range of issues involved in  leadership and management, but it is recommended that the Institute focus on those issues that are particular to surgery, contextual leadership and management to use the jargon.

Walking Therapy

How do we know that walking does more good than harm?

One source of evidence is that the people who walk say that walking makes them feel, and look, good. But this does not prove that walking is beneficial or, as is said when new medical treatments are evaluated, that it does more good than harm.  It might be that people who feel good about themselves and who are healthy, walk more than people who are depressed or unwell, and there is probably some truth in that

A second method is to question people with a problem such as heart disease or depression about their lifestyle before they became ill, and compare their answers with the results of interviews of another group of people chosen because they are identical to the group that is ill – for example, same gender, same social class, same job – in fact being as similar to the people with the disease as possible except for the fact that they do not have the disease. This approach produces scientific evidence but, like all scientific methods, has its flaws. For example, one study of four questionnaires used in interviewing people about their exercise habits demonstrated that very different results were obtained, depending on which questionnaire was used. The answers given by the same people ranged from 81 minutes in response to one questionnaire to 242 minutes in response to another.

Pedometers do away with the problem of both memory and questionnaires, but you cannot go backwards in time so studies of walking, and other forms of exercise, have to rely on memory as well as questionnaires, and both are unreliable

In spite of these difficulties, there is now a large amount of evidence about the benefits of walking.

A drug has indications and contra-indications.   The indications are the reason why a drug should be prescribed, the contra-indications are reasons why it should not be prescribed.   For example, bacterial infection of the tonsils is an indication for penicillin, but allergy to penicillin is a contra-indication.   There are many indications for walking, but what about the contra-indications?   Some people with chronic conditions worry about taking more exercise, but there are no chronic conditions or diseases for which walking is contra-indicated.   Walking has been shown to be beneficial for many diseases, including:

  • heart disease
  • diabetes;
  • arthritis;
  • intermittent claudication;
  • osteoporosis;
  • lung diseases;
  • cancers;
  • psychological problems

One reason why walking is helpful in so many chronic diseases is that it tackles a complication common to all chronic conditions – loss of fitness.   Disease has direct and indirect effects. The disease directly affects certain parts of the body.   In coronary heart disease, for example, the arteries to the heart itself are affected; in neurological disease it is the brain. However, many chronic conditions also have indirect psychological and physical effects, most commonly depression and loss of fitness

A vicious cycle develops. The disease causes inactivity and the inactivity itself increases joint stiffness and the loss of muscle power, making the person feel even more depressed.

Erewhon Healthcare System

A system is a set of activities with a common set of objectives and an annual report. For each objective one or more criteria are identified to measure progress or the lack of it and for each objective standards have been agreed and there are three standards:

  • A minimal acceptable standard, for which no service should fall;
  • An excellent standard, the best standard of care in the world;
  • The achievable standard, the level of performance that distinguishes the top quartile of services worldwide from the rest.

These 3 levels of standards have been chosen because experience has shown that simply asking people to be the best, an approach once popular based on the book called “In Search Of Excellence” can be disheartening to those who are far away from the best or for those who see the best services delivered by what they perceive to be services privileged by either an excellent investment or rich resources, for example by charismatic or excellent people, as a result of chance. By identifying the achievable standard however is usually possible for a service in the lowest quartile to being shown a service serving a population in the top quartile which is very similar in terms of wealth and deprivation. Services in the top quartile can of course be encouraged to try to equal the best and the best service itself will be constantly looking for ways to do even better.

Systems of care are based on symptoms such as headache or pelvic pain, on diseases such as bipolar disorder or asthma or stroke or on population subgroups such as children or frail elderly people or people with the triple diagnoses namely physical health problems, psychological health problems and substance abuse, sometimes called people with co-morbidity.

It is useful at this point to distinguish between complexities and complicated because when describing the systems approach of Erewhon to clinicians from other countries they often remark that people have more than one condition. We recognise that maybe people have complex problems, for example an 81 year old woman with 4 diagnoses and 7 prescriptions who is looked after by her 52 year old daughter who lives 2 miles away and who has an alcoholic abusive husband and an unemployed son living at home. This is complexity but it is the need meant frequently by general practice or family medicine. Generalists excel in the management of complexity. Of those 4 conditions diagnosed one may cause problems from time to time requiring referral to a specialist because the problem has become too complicated for the generalist. Specialists excel in managing the complicated. The relationship between generalists and specialists need to be carefully worked out but the distinction between complexity and complicated is accepted as part of the language of the Erewhon Health Service.

Erewhon Healthcare – The Best in the World

Erewhon has a population of 5 million people. It is a population with an age distribution typical of most developed countries with about 15% of the population over the age of 65, and the population is ageing. Most live in cities, with two big cities each with a medical school, and city living is increasing and there are some thriving towns and some depressed industrial areas and large sparsely populated rural areas.

The economy of Erewhon is improving slowly but taking into account the impact that population ageing has on health and social care; it is wise to work on the assumption that there will be no real increase in resources available for health and social care.  The population of Erewhon is covered by a payment system that is based on combination of tax and insurance but the responsibility for health services is discharged to 10 geographical areas each with a budget taking into account age and deprivation. They have the responsibility for resource allocation; the responsibility for health service provision is based primarily on programmes and systems. Each of the populations, served by the Health Boards called A-J, happen to have a hospital, largely for historical reasons, with two of them being larger teaching hospitals and there are ten Mental Health Services and about 50 general practice teams in each.

Ten Key Value Questions in Choosing Healthcare

For decades to come need and demand will increase faster than the resources available. Society will need to maximise value from the resources it allocates for public services including healthcare and to do this ten questions need to be addressed

Question 1: How much money should we spend on healthcare?

Question 2: Is the money allocated for the infrastructure that supports clinical care at a level which will maximise value?

Question 3: Have we distributed the money for clinical care to different parts of the country by a method that recognises both variation in need and maximises value for the whole population?

These questions are primarily the responsibility of the Cabinet and the Secretary of State for Health. Then comes the role of the Commissioners. They will want they resources they allocate to be used in ways that have a positive answer to questions 5-10 but they hold those to whom they have allocated resources to do this. The answer to Question 4 is, however the primary responsibility of commissioners. It is important to note that specialist commissioners produce some of the answers to question 5 but do so with regard to the effect their decision this has on the distribution of resources to the different and the thirty sub groups of the population outlined in Appendix 1

Question 4: Has money been allocated to different patient groups in a way that is not only equitable but also maximises value for the whole population?

Question 5: Are all the interventions being offered likely to confer a good balance of benefit and harm, at affordable cost, for this group of patients?

Question 6: Are the patients most likely to benefit, and least likely to be harmed from the interventions, clearly defined?

Question 7: Is effectiveness being maximised?

Question 8: Are clinical risks being minimised?

Question 9: Can costs be cut without increasing harm or reducing effectiveness

Question 10: Could each patient’s experience be improved?

This game focuses on Question 4 which is not only a responsibility of commissioners. They have to make decisions about the allocation of resources between programmes, for example between respiratory disease and cancer. Clinicians will be responsible for the allocation of resources within programmes, for example between asthma, COPD and sleep apnoea within the respiratory programme budget and, with patient involvement making decisions within each system , and the STAR tool is a related game designed specifically for this purpose (2)


There is a negative, over pessimistic view of old age and older people. This derives partly from a failure to understand how many of the problems of old age are preventable and are not due to the ageing process. Poverty, for example, leads many people to withdraw from society but it is not a consequence of ageing. It is a consequence of social inequality and injustice. Some individuals can retain a positive attitude in the face of the these negative pressures but this requires resilience and a definitely decision to think positively about one’s position, capabilities and potential.

Disease Prevention

For most people, old age is feared because it is associated with disability and disease, and it is true that the prevalence of disease increases decade by decade.   However, the ageing process is not the principal cause of disabling disease, and many of the disabling diseases of old age are preventable.

It is true that disease occurs more commonly as we grow older. With every year that passes the probability that a person will develop or be diagnosed as having a disease increases but this does not prove that ageing causes disease. The reason for this increase is the ridiculously simple explanation is that every year that passes means that the person has been exposed for yet another year  to the risk factors that cause disease.  It is usually the length of exposure to risk, both environmental risk and lifestyle risk, that causes the increase in disease not the ageing process.

About Ageing

There are only two phases of life, the phase of growth and development and the phase of ageing and functional decline which is at present untreatable but there is great interest, and considerable investment, in the search for what would have been called an Elixir of Life but is now called Regenerative Medicine

It is important to appreciate just how serious people are about this mission. The key term is Regenerative Medicine and particularly in the USA where big powerful research centres, like the SENS Research Foundation in Mountain View, California, based on their belief that ‘ a world free of age-related disease is possible’ and new companies. The Financial Times (FT) on its front page on the 5th of September 2014 that Arthur Levinson, who developed Genentech, the company that was the first to use the knowledge locked in the human genome to create new  drugs, had resigned from the board of Roche, which had bought Genentech. The reason was to devote himself to this mission. The ‘ 64 year old’, as the FT pointed out, who is also chairman of Apple, will head the mission started by Google, also based in Mountain View to extend healthy life. The new company he will lead is called Calico, short for California Life Company, not only has the firepower of Google behind it but  will also benefit from a huge investment from another drug giant called Abbvie

Yippee I am 76!


Yippee I’m 76!   It’s hard to believe it – where did all those years go?  And do you realise it’s been 32 years since the birth of breakfast television – when we the BBC pipped our arch rivals ITV to be the first network to win the early morning TV viewing audience?   I was lucky enough to be there on the very first day, a leggy six foot blonde filmed doing a star jump on Waterloo Station in front of a bunch of bleary eyed commuters.

Most of them didn’t have a clue who I was but whilst I continued to put those en route workers through their paces the national press were jamming the BBC switchboard demanding to know who the bird in the shiny bright green leotard was. The PR in charge told them I was Diana, their goddess, because that was their nickname for me. Then as an afterthought he said, ‘our green goddess’ and the name’s stuck ever since!

I was 45 fit as a fiddle and supple as a reed which I put down to my own regime of exercise and healthy eating, completely self taught. The concept of aerobics and formalised exercise regimes simply didn’t exist before I came on the scene and it has been said that I pioneered the idea of structured fitness routines in the UK, at the same time that Jane Fonda was establishing her credentials as the first lady of fitness across the Atlantic in the US. However our approaches couldn’t have been more different. While Jane was ‘going for the burn’ with her hard on the bones high impact aerobics (now considered largely unsafe), I was going for a gentler, kinder on the joints, low impact type of routine. In the early 1980’s there were no health clubs or personal trainers in the UK as we know them today, and only a few fitness classes such as the League of Health and Beauty and the Keep Fit Association.

They say that necessity is the mother of invention and in my case it’s probably true. For me it all started 40 years ago, when I had my ‘first wake up call’ health wise.  At 30 I found myself in hospital after it was discovered I had a cluster of lumps on my thyroid. As a result I had a partial thyroidectomy, a pretty major operation at the time. Afterwards, as I was lying in bed I realised I wasn’t as fit as I used to be – I used to run for the county and played a mean game of tennis in my teens but all that went by the by when I had my children, I’d married at 19 and had my first son at 21. So when I came out of hospital I was determined to regain my strength and stamina and find out as much about exercise as I could.’

I was surprised to find there was very little in terms of information. ‘There weren’t the glossy exercise guides or fitness CD’s like we know them today. Eventually I found a book on fitness devised for the Canadian Air force plus a few obscure guides on yoga, then came across The League of Health and Beauty and between all these cobbled together sources I put together a keep fit programme for me.’

I had no intention of taking it further but friends started pestering me to help them get fit too.   I was the first to have my babies at 20 and 21 and when my girlfriends started their families years later they came to me asking how to flatten their tums and tighten their bums after the toll of pregnancy, so we got down on the floor in my living room. BBC Radio 1 was always on, playing music in the background, so I struck on the idea of putting the routines to music, making my own tapes.

One thing lead to another. A friend who was a domestic science demonstrator was heading up a publicity campaign for a diet spread called Outline and the makers wanted someone who could devise some exercises to ‘suit your Outline’ and she recommended me.   As a result I found myself testing out my exercise regime on a much larger audience – holiday makers at Butlins where Outline were piloting their PR campaign. It blew them away. I remember that first day, striding out onto the ballroom floor in front of a sea of holiday makers – grans, granddads, mums and dads and kids – telling them to get down on the floor, kick off their shoes, loosen their belts and copy my moves. They all loved it. Outline and Butlins were thrilled, so much so that I was asked to replicate the idea at the other Butlin’s camps and within a few months was training up girls to head up fitness classes all over the UK.

But my holiday camp work wasn’t the only thing keeping me busy. After recovering from my thyroid operation I joined BBC Radio Bristol as a contributor (a young Kate Adie was my boss).  Prior to that I’d enjoyed a highly successful 10 year career as a model after being spotted at a charity fashion in a Bristol Department store where I had worked full time as a young personnel and welfare officer.  I was lucky, my long legs and slender figure were my passport to modelling success all over the world for both catwalk and photographic work.

My TV debut was first as a Continuity Announcer for HTV West and then on a network programme called Here Today made by HTV where I became one of the presenters – at age 40.  On Thursdays I’d do my TV stint in Bristol in the morning before changing into my tracksuit and sprinting over to Butlin’s the  Barry Island holiday resort in South Wales to do my live exercise classes in red leotard and tights.. Then one day someone suggested I replicated my routines on Here Today.

They asked me to choose a leotard colour I could wear specially for the programme – they didn’t want me in the red I was wearing for my holiday camp work so I suggested yellow. I modelled it for them and they were horrified – they said I looked like Rod Hull’s Emu! Then I tried a sophisticated brown which was rejected because in it I appeared nude on camera. The only leotard colour left that was telegenic and suitable was green, which is how that came about. I introduced the leg warmers to hide the wire leading to my mike pack strapped around my right ankle after I heard one woman commenting on what she thought were my ‘terrible varicose veins’!’

So for the next three years I honed my TV fitness slots on the local HTV station, serving the West Country, before I got the telephone call which was to change my life.

A producer called asking me for an interview – I took down the name and number not realising it was for the new national breakfast TV station, The following day I mentioned it to a friend at work and it was only when I whispered the address that I found out the audition was for the BBC, not ITV, who I’d been working for up until then.

As they say – the rest is history. I got the job and days later was seen doing that famous ‘star’ jump in the air, capturing the birth of breakfast TV ushering in the rest of the team comprising Selina Scott, Frank Bough, Glyn Christian and Russell Grant.  Amazingly” The Green Goddess” became famous overnight. But success came at a price.

My marriage to John didn’t survive the heights of my TV career. When I was offered the job presenting a seven minute exercise slot on breakfast TV five days a week I said ‘yes’ on the condition I could film the slots near my home in Bristol. The boys were grown up, but that’s where I had been living with John for 25 years. To be fair the BBC agreed.  But when they saw how well my exercise slot was working out on location, it was never going to happen in a studio. And from that moment onwards I lived out of a suitcase – for the next four years I was constantly travelling the length and breadth of the UK performing my slots in schools, old people’s homes, factories, shopping centres, hospitals, you name it.

Things didn’t always go according to plan. Once when I was filming in a health club at Roehampton, my class, who happened to be mostly male that day, were performing deep knee bends. I looked up to camera and with a completely straight face said ‘as you can see it’s not only balls bouncing on the court this morning, its members too!’ I didn’t have a clue that I’d said anything remotely funny, even when half of the class collapsed in fits on the floor. Needless to say I had a call later that day from Esther Rantzen who told me to tune into That’s Life the following Sunday because they’d been inundated with demands to repeat it. I recall sitting on the sofa next to my grown up boys who roared with laughter when they saw their mum drop such a clanger.

My stint on breakfast TV ended after four and a half years when a new Editor arrived with a bref to make the programme ‘more serious’. In  came more news and out went the lighter strands like cookery and fitness – it proved disastrous for the viewing figures, but by then I had moved on to front another health and fitness programme, Look Good, Feel Great for Central TV.  Ironically, bearing in mind the title of the show, I had my second major ‘wake-up call’ when I was diagnosed soon after with breast cancer.

I’d gone to a clinic to find out about HRT but when they did some routine health checks they also took a mammogram and spotted the cancer. It was a dreadful shock. Everything seemed to be going so well and I suddenly felt cheated.  It was 1987, 22 years ago when cancer wasn’t talked about openly – people shuddered at the very mention of ‘the big C’.

By then I was separated from John, a single woman living in London and having to support myself so I didn’t tell anyone about the diagnosis.  I underwent what was then a revolutionary procedure, a double mastectomy with immediate reconstruction, and was back on air, in my leotard performing her daily exercise classes three months later.

It was six months before anyone knew I’d even had the breast cancer or such an extreme operation.  Life gradually returned to normal but a few years later was a terrible time for all sorts of reasons. I was to discover that my new partner, who I had put my trust in and loved, had been having an affair with a call girl throughout our time together. He left me while I was undergoing further breast cancer treatment and I never saw or heard from him again. It was the ultimate betrayal. I sank into depression but eventually managed to pull myself back from the brink with the news that I was to become a grandmother. All my life I’ve been very good at turning negatives into negatives. It’s a big mantra of mine. I do believe what doesn’t kill you, makes you stronger.

And here I am celebrating my 76th birthday. I’m still slender and supple and can still perform all the exercises I devised four decades ago which helps me to look and feel good.  In fact I have just made another fitness DVD called EASY FIT to be released Jan 2010.

I haven’t had a face lift, Botox or any other type of cosmetic surgery – I’ve had enough surgery for medical reasons to ever contemplate that, I think it’s more about attitude and enthusiasm for life that keeps me young. I’m as active as ever, regularly cycling, I have seven bicycles (to accommodate all sizes and ages of friends and grandchildren) and I walk twelve miles at a time and do masses for charity.  I’m patron of the Breast Cancer Campaign and am heavily involved in Breast Cancer Care and Cancer Research UK.  I help with charity events including Fun Walks and Treks like the 10k and 20k Ribbon Walks for Breast Cancer Care.  I’ve just completed a fitness training video for Cancer Research and regularly work on the cruise ships doing motivational talks and heading up the on board fitness classes.  I am a regular guest presenter in two health resorts in the Caribbean. One of my proudest recent achievements was trekking The Great Wall of China last year, covering 25 miles a day at tremendous altitudes. I was the oldest in the group which raised £140,000 for charity.

I can’t imagine ever slowing down. Even my second brush with cancer four years ago when skin cancer was diagnosed, the result of sunbathing 30-40 years ago, hasn’t quenched my zest for life.  I noticed a patch of skin on my shin which didn’t seem to heal, I got it checked out and it was diagnosed as a basal cell carcinoma. I had it treated with a special type of scarlet laser but more patches can appear, so I have to be vigilant.

Being 76 was a great excuse for a fantastic party. I invited all my family and friends, those who’ve stuck with me through thick and thin. Women of my age are so lucky. The image of age has totally changed, and at the moment I don’t feel there is anything I can’t do. My boys, Tim who’s 48 and Nick who’s 46, say I’ve lived my life back to front. Here I am doing all the things I wanted to do as a teenager like being able to go off on adventures, like trekking the Great Wall of China, and last year I also sailed down the Amazon.  My dad, who was very strict, refused to let me go to college to be a PE instructor when I was young because he said it wasn’t a “proper job” for a young lady.  But I ended up becoming the nation’s number one gym mistress so it just goes to show, you can do it.  All it takes is the courage and conviction to go out there and get it!