Diabetes Today 1/5: ‘Medtech needs to focus on value’, says expert Muir Gray

Health systems need to embrace high-value technology – and stop overusing low-value technology – if we are to meet the challenge posed by diabetes and other chronic diseases

One in 12 people in the world has diabetes. That’s around 387 million. By 2035, the number of people living with diabetes will increase by 205 million.

Most will require health services for the rest of their lives and, if their condition is not well controlled, could face serious complications.

Dealing with this and increases in other chronic conditions is a major challenge for health economists and policymakers. Value-based healthcare has been proposed as the ‘strategy that will fix healthcare’. Proposed by Harvard’s Michael Porter, this big idea can be summed up as ‘outcomes that matter to patients, divided by the cost of achieving those outcomes’. In essence, it demands a more patient-centric care and closer measurement of clinical and quality of life outcomes.

Professor Muir Gray, Director of Better Value Healthcare and previously Chief Knowledge Officer at the NHS in the UK, says this focus on value is imperative. ‘Focusing on value is inevitable,’ he says. ‘The money has run out.’

However, while he says Porter’s prescription for measuring outcomes is vital, Gray says the model does not go far enough for countries with universal health coverage – that is, any developed country other than the US. ‘Porter’s American approach to value doesn’t consider whether we are allocating resources to particular populations in need – people with cancer or respiratory disease, for example – or whether we are using the allocated resources for the people who would benefit most,’ he says.

Gray’s critique is that the definition of value-based healthcare currently used in the US aims to get the best outcome for a patient presenting at a particular clinic, but doesn’t help a health minister, payer or insurance company who is responsible for the health of an entire population.

Decision-makers in universal systems need to live within finite budgets; consider equitable access to care; support preventative measures to reduce future costs; and ensure they have a well-functioning health workforce. In return, policymakers know that good health outcomes have positive economic and social effects – keeping people in work, reducing their dependence on welfare and freeing them up to provide informal care. These elements are not always captured by proponents of value-based healthcare.

‘The American definition of value is about outcomes and the resources needed to achieve those results,’ says Gray. ‘We would call that efficiency. Porter's approach may not always fit the healthcare model in countries with universal healthcare coverage where we are talking about making public health systems sustainable.’

Gray prefers the example of Scotland’s Realistic Medicine programme where doctors are encouraged to accelerate the adoption of high-value innovation and to quickly abandon low-value technologies and drugs.

‘We need to put much more focus on prevention and pay greater attention to measuring outcomes and determining from which budget it should come,’ he says. ‘We need to factor in the resource time of patients and health professionals, and consider sustainability in the broad sense.’

This, says Gray, means accounting for the carbon footprint of devices and drugs. ‘The good news is that when we ask frontline clinicians to think about carbon they are highly motivated and think more carefully about their decisions.’

When it comes to managing diabetes, Gray believes medtech plays a very important role in monitoring type I diabetes in particular. For people with type II diabetes, he sees other technologies as having a key role in containing the growing impact on health services.

‘I would say that a programme of brisk walking on an app may be as an important as blood glucose monitoring,’ he says. ‘Indeed, I sometimes say that key pieces of technology in the fight against diabetes is the measuring tape or the bathroom scales.’

Gray says smartphones and fitbits will also have an important role to play in tackling the type II diabetes problem which has been exacerbated by sedentary lifestyles.

Crucially, most diabetes cases must be managed by patients themselves and in the community care setting. ‘We mustn’t think of the health system as a set of boxes side by side which separate hospital, community and home care,’ he says. ‘It’s more like a set of Russian dolls. The biggest is self-care; inside that is informal care provided by family and friends; then comes care provided by nurses and GPs; and finally, specialist care from hospitals. That is why self-care technologies will be important but they must be well evaluated if they are to be funded.’

Gray also emphasises the need to consider how any new technology will be funded. ‘It is important to think of a single budget for type1 and type 2 diabetes,’ he says. ‘If a new technology is developed, it will need to be funded from existing resources, perhaps by reducing expenditure on drugs to allow the money to be switched to the new technology. Developers of medtech need to understand the whole system, not just the part their technology plays within it.’



Muir Gray entered the public health service by joining the City of Oxford Health Department in 1972. The first phase of his professional career focused on disease prevention and health in old age, followed by the development of the NHS screening programmes as well as services aimed at bringing knowledge to patients and professionals, including the NHS Choices.  He has also been instrumental in setting up the Centre for Evidence Based Medicine and the Cochrane Collaboration in Oxford.  During this period he was appointed as the Chief Knowledge Officer of the NHS in England.  He is a Visiting Professor in Knowledge Management at the Department of Surgery and a Visiting Professor of Value Based Healthcare at the Nuffield Department of Primary Care Health Sciences.