Bone Strenthening Exercises & Tips For Those Who Suffer From Osteoporosis

You’re never too old to improve bone and muscle strength, even if you actually suffer from osteoporosis. Before-and-after research with very elderly people has demonstrated the benefit of bone-loading exercise and also shown how mobility and muscle power enhance even simple activities like getting up from a chair, lifting parcels or going up stairs. Of course these benefits also reduce the risk of falling and suffering a fracture. Should you have the bad luck to fall, you’re less likely to suffer serious consequences.

One study showed that 30 exercising women with an average age of 84 showed bone gains of over 2% compared to an inactive group who lost over 3% of bone thickness when monitored by researchers for three years.  What makes this study remarkable is that they did it sitting down! Their routine included knee lifts, toe taps, arm lifts, sideways bends, leg spreads.  The exercisers worked out for 30 minutes a day, 3 days a week.

Thin old people are more likely to fracture their hips when they call than their plumper contemporaries. Some researchers suspect that the fat acts as a kind of shock absorber. Hence the arrival of the energy-absorbent hi-protector, a padded device developed in Denmark that can be worn by anyone frail and elderly and at risk of damaging falls.

An 8-week programme of ‘high resistance’ training followed by 10 elderly people in an American residential home resulted in spectacular gains in muscle strength.  Muscles were more flexible afterwards too, another vital  weapon in the fight against falling.

Improvements in muscle strength can come within weeks of doing regular daily exercise, but bone-building takes longer. There may even be an initial period when bone gets slightly thinner, but after a year, improvement should be discernible.

If you already suffer from osteoporosis, there’s no need for us to remind you of the discomfort and pain you experience.

If you have the disease in your spine, particularly in your lower-middle back below the ribs, you may be permanently bent over and unable to hear weight through your spine.  In this case, we know, exercises are difficult and in some cases impossible to perform.

The best treatment for sever sufferers is pain-relieving drugs prescribed by the doctor and rest in bed with a pillow under the head for support. One pillow if possible  though we know some people can only find relief with more. Add a pillow under the knees and relax with legs straight if you find that more comfortable.

Most people, however, can benefit from some exercise, and I have designed our Osteo-Relief Bone Strengthening specifically for osteoporosis sufferers. Do them on a regular basis for at least 3 months before you expect to see any improvement. Don’t be discouraged if you feel initial discomfort. After a fall or operation, it is often difficult to overcome the pain barrier – the fear of pain, in fact. But remember the rewards in terms of regaining mobility, strength and independence, and try to stick it out.

If you have any doubts, show the exercises to your doctor or consult a trained physiotherapist. The extra stress on bones during exercise is not appropriate for people with advanced osteoporosis and could result in fracture.  Seek medical advice if you think you are  at risk before attempting Osteo-Relief Bone Strengtheners.

People without osteoporosis who have been actively exercising during their middle years can, and indeed do, continue at a high level of physical activity through out life, but late-starters need to take it nice and easy, putting the emphasis on walking, swimming, dancing and low-key routines like the one we suggest here.

A brisk daily walk is healthy and beneficial for anyone and everyone.  Not only does it increase our stamina, strengthen our heart, improve circulation and tone up our muscles, but it’s a Bone Booster too. A simple walk costs nothing and gives excellent results – so off your bottom and get those boots walking.  Keep to a brisk pace and walk for at least 20 minutes.  You should puff a bit!


The following 5 exercises are particularly beneficial if you already suffer from osteoporosis. They will help strengthen your spine and correct your posture


Lie on your bed with your knees bent and a small pillow to support your head. Fix your eyes on a spot above you, and simply push with your neck and stick your chin up and out. Retract your chin and pull it down into your chest as far as you can. Continue with this ‘chicken neck’ exercise for 1 minute. As you progress over the weeks, remove the pillow but keep your knees bent and continue the exercise for 1 minute. Aim eventually to lie out on the floor without the pillow and with legs straight to do the exercise.


Lie on your bed, preferably without a pillow, with both knees bent and arms out to your sides, opalms down. Keep your feet in contact with the bed and roll both knees together over to your right side as far as comfortable. Try to look over to your left hand. Hold 2-4 seconds. Slowly bring your knees back to the centre, and carefully roll them over to your left side and try to look right. Hold 2-4 seconds. Keep your upper back, shoulders and arms in contact with the bed throughout the exercise. Aim to do 4 rolls to each side, and eventually to do the exercise on the floor.


To strengthen your tummy muscles like on your bed with your head supported by a small pillow. Bend your knees up, feet down flat on the bed. Place your left hand behind your head (or neck), and extend your right hand on to your right thigh. Breathe out and lift your head and shoulders up, sliding your hand up to your knee. Breathe in and relax back down. Continue 4 times, then change hands and repeat 4 more lifts with your left hand on your left thigh. Aim eventually to do this exercise on the floor without a pillow, but always with your knees bent.


Lie on your bed without a pillow, with your knees bent and feet flat down. Place yur hands up on your thighs. Clench your bottom and lift it up off the bed. Hold for 2-4 seconds and carefully relax back down. Repeat 8 times, and try eventually to do this exercise on the floor.


This exercise is best performed on the floor. Lie out on your tummy, chin to floor. Place your hands under your shoulders with your fingers turned slightly inwards.  Breathe out and push yourself back to lift your shoulders and chest up off the floor. Breathe in and relax back down. (Keep your chin facing down as you lift up,) Repeat this exercise 8 times.

When you first start this exercise you may need several pillows under your tummy in order to get comfortable and completely straight before attempting to bend backwards.

  1. RELAX

Lie on your back with your head supported by one pillow, (more may be necessary in severe cases). Place another pillow behind your knees and thighs to help relieve pain. Place your hands comfortably on your rtummy. Breathe deeply, taking the breath into your abdomen, and feel the rise and fall of your tummy with your fingers.  Close your eyes and relax.

It is often difficult for those who have vertebral factures, with painful, tender spines and limited mobility, to lie on their backs.  You may find it easier to try an alternative starting position for some of the exercises, such as sitting, from which you can do head and upper back exercises.

People who have already fractured their vertebrae can also benefit from exercise, to strengthen the muscles around the hips and knees – strong muscles in the legs help to prevent falls, which may well lead to fractures.

For information and further specific illustrated exercises for osteoporosis sufferers, contact the National Osteoporosis Society for their booklet Exercise and Physiotherapy in the Prevention and Treatment of Osteoporosis.


Walk tall is tough advice if you suffer from a curved upper spine, but, nevertheless, it’s exactly what you need. Get into he habit of checking that your shoulders are down and back, your chin pulled in and your weight evenly distributed. Hold your abdomen in if you can. Check your posture by standing against a wall:heels touching it, no hollow back. If you can’t get your head straight against the wall at first, keep practising.

Don’t slump when you sit, get your bottom well back into the chair. A soft, low armchair may seem like luxury, but if it makes you sink too low and rounds your back, change to something more upright with a high, firm back. A rolled towel at he back of your neck and another supporting the small of your back will enhance comfort and remind you to sit upright when reading. Make sure your feet are resting easily on he floor, and when you get up, resist bending forward. Keep as upright as possible and then stand up straight. You may find that at first you need to hold on to something as you get up, but gradually you’ll be able to do it without the help.

A supporting mattress doesn’t have to be iron-hard, and you don’t need special orthopaedic types. On the other hand, it shouldn’t sag. Buy a new one if yours shows signs of wear, and if it feels a bit on the hard side after that comforting sag, put a quilt over it and sleep on that to soften the blow.

Practise getting up and down from the floor once a day. It will help lessen the impact should you accidentally fall.

Start by standing beside a steady, upright chair, holding the back with the left hand. Get down on your left knee, keeping your back straight, then take the right knee down, letting go of the chair and go down on all fours.  Swing your bottom over to the floor on the right and sit down, Stand up in your own time, using the chair as support.

Guard your back when lifting anything heavy. Get as close to the object as possible, go down on one knee to pick it up, hug the load to your abdomen and lift with the strength from your legs by pushing down firmly with both feet. Don’t try to take on too-heavy loads.

Remember, calcium helps reduce bone loss in older women. Recommended daily allowances are give on page… and calcium supplements have been shown to have a protective effect.

Poor diet not only leads to malnutrition and muscle weakness, it can also mean shrunken jaws and loose-fitting false teeth. Cooking for one doesn’t have to be a chore. Even if someone else does the shopping for you, when it’s cold and wintry outside, make sure you give them a shopping list that includes daily helpings of fresh fruit and vegetables, fish and dairy produce, and not too much fried food.

How to prevent falls

  • Get rid of loose rugs, avoid slippery floors.
  • Get better lighting, especially in hall and on stairs.
  • Have a good grip handle on bath, and a non-slip mat in it.
  • Get eyesight checked regularly.
  • Keep a hall or landing light on at night.
  • Watch out for uneven pavements – use a walking stick to help keep your balance.
  • Wear well-fitting, supporting, non-slip shoes.

Osteoporosis: Vitamins and Minerals

Why do we need vitamin D?

We need Vitamin D in order to absorb calcium properly. But as we grow older, we become less able to utilise the vitamin, and a deficiency may lead to muscular weakness and contribute to instability, falls and subsequent fractures. Some drugs interfere with Vitamin D absorption. If you regularly take any drug, ask your doctor about this.
Many dietary sources of Vitamin D are oily fish like herring, sardine, mackerel; also egg yolk, milk butter, cod liver oil.

Some foods like breakfast cereals, margarines and skimmed milk powder are fortified with Vitamin D – if so, this will be stated on the pack.

We also get Vitamin D from sunlight, which is why getting out into the fresh air in winter as well as summer is important, especially as we grow older and may give in to the temptation of staying indoors. Some calcium supplements include Vitamin D as the natural complement. It is generally better to take a combined supplement rather than trying Vitamin D alone, in order to get the right balance.

It’s not fully proven, but there is some evidence that if you’ve had children you may be less susceptible to osteoporosis. The advantage may come from increased intake of calcium rich foods, which many pregnanat women include in their diet. Also, high levels of oestrogen during pregnancy boost Vitamin D productivity which in turn promotes calcium absorption. And on top of all that, the hormone progesterone, which is present in higher levels in pregnancy, adds to the bone conserving effect.

Magnesium – another part of the jig saw
The mineral magnesium is thought to help stabilise hormones that control calcium balance and can help increase the efficacy of Vitamin D. Western diets contain very variable amounts of magnesium, and there’s a school of thought that supports increasing dietary intake of the mineral as a way to keep bones strong, especially if you are increasing calcium.

Orthodox medicine does not hold with the idea that we may be magnesium deficient, but it’s as well to know which foods contain it. One of the best sources is cocoa, which means that it is also in chocolate, both milk and plain.
Other sources are wheat bran, nuts, tea and coffee, oats and rice. And it comes via the tap in drinking water – more in hard than in soft water – so make a habit of drinking several glasses a day.

And finally, phosphorus
This mineral also plays a part in calcium absorption and in the formation of tissue between bones. We get it in meat, poultry, fish, cereals, soft drinks, and it’s highly unlikely that we get too little.

Should I take a multivitamin pill?
If you are concerned about receiving sufficient nutrients in your daily diet, the answer might be to go for a multivitamin pill that offers a balance of various vitamins and also minerals. You won’t get as much calcium in a multi-pill as you do in calcium-only types though. Look on the labels to compare contents. In any case, a vitamin pill is not an excuse to give up being concerned about what you eat. A balanced duet is important for general fitness and health, whatever supplements you take.

The good mid-life diet
• Reduce sugar, not only in tea and coffee, but by choosing natural, unsweetened fruit juice instead of canned soft drinks. And don’t forget the sugar content of cakes, biscuits, puddings and jams.
• Reduce salt, both in cooking and when seasoning food at the table. Some salted foods need to be eaten sparingly; crisps, salted nuts, smoked fish, smoked bacon, smoked meats like salami.
• Eat vegetables and salads daily. Best is combination of green, leafy vegetables, yellow and red vegetables, peas and beans for fibre content and uncooked salads. At least 3 helpings a day.
• Have fresh fruit daily. At least 2 servings.
• Go for fibre. You’ll get it in cereals, and it’s a way to make calcium-rich milk go down too, so try to eat at least one helping a day. Other fibre foods which can protect against heart disease and bowel disorders are bananas, avocado pears, celery, fresh fruit, lentils and other dried beans and pulses, and oatmeal. Remember, unprocessed bran can hinder calcium uptake, so avoid the stuff.
• Limit meat consumption. Red meat is best kept to 2 or 3 helpings a week; substitute chicken, fish, nuts as sources of protein.
• Limit fats and dairy products. To protect against heart disease, fat intake should be about a third of total calories consumed. Use olive, sunflower, safflower oils rather than animal fats for cooking, whether it’s roasting, frying, or in salad dressings. Choose skimmed milk, low-fat yoghurts.
• Drink plenty of liquids. It can be water, up to 6 large glasses daily, or fruit juice, or herbal tea which is, of course, caffeine-free;
• Alcohol consumption should be limited. Maxuimum safe limit for women is 14 units a week. 1 unit being half a pint of beer or a small glass of wine or standard measure of spirits. Alcohol can cause flushes, and in excess hampers calcium absorption and damages bone cells, so drinking even less is better.

What if I smoke?
As well as all the other horrors connected with smoking, it triggers and early menopause and is strongly associated with risk of fractures. Even some passive smokers, women who live with heavy smokers, have been found to have an earlier-than-average menopause with risk of greater reduction of bone density.
Keep your coffe intake down and don’t take it black. An American study shows that drinking more than 2 cups a day appreciably reduces bone density, though women who also drank a least one glass of milk as well lost less bone density than other coffee drinkers.

The fringe and beyond
Claims for various ‘alternative’ ways to combat osteoporosis make headlines from time to time, some of which are based on research, others merely on passionate conviction. A trace element called boron has been named as a vital ingredient in maintaining calcium levels and so reducing bone loss in post-menopausal women. The results seem impressive – calcium loss reduced by 50%, blood levels of oestrogen doubled in one report – but as is so often the case with alternative remedies, the number of women studied was very small, just a dozen, and more research is needed before claims can be justified. But boron exists in fruit such as apples and pears, in leafy vegetables and nuts, and is available at health food stores in tablet form, though most nutritionists would’nt recommend buying it.

Yet another trace element, silica, is said to ‘empower’ calcium and therefore prevent osteoporosis, as well as strengthen nails and hair. The orthodox view is that we get enough in our diet, since silica is present in the earth, but the alternative view is that high-tech farming has destroyed it and modern food-processing removes what little is left. Brown rice, wholemeal flour, fresh fruit eaten with the peel intact and organically-grown products can provide silica.

Another branch of the alternative fringe, Chinese medicine, advocates herbal concoctions that act on the kidneys. Recent reports on possible kidney damage from Chinese treatments suggest that this one should be approached with great caution.

How to combat aging

Researchers now agree that destructive molecules known as free-radicals are responsible for many of the age-related degenerative diseases conditions in the human body – for example, wrinkles, memory loss, arthritis, atherosclerosis (which causes heart disease) and cancer-causing mutation in cells. The good news is that you can limit the damage inflicted by free-radicals and therefore affect the rate at which you age by making changes to your diet and lifestyle to reduce the levels of free radicals in your bloodstream.

What are free radicals?
Free radicals are electrochemically unstable molecules, generated within our bodies by normal metabolic functions such breathing, digesting foods and fighting infections, as well as factors such as certain foods (for example, heated fats), overeating, smoking, stress, sunburn and pollution. In large quantities, free radicals can damage DNA, accelerate aging and contribute to a wide range of disorders.

Anti-ageing regenerative plan!
Arm yourself with antioxidants
Antioxidants are nutrients that seek our and neutralise the cell-damaging free radicals, blocking their path of destruction. In this way they help ward of cancer, heart disease, high blood pressure, stroke, alzeimers disease, cataracts and other age-related illnesses and conditions, hence their renown as anti-aging nutrients.

The key antioxidants are beta-cartotene (which the body converts to vitamin A), vitamins C and E and the minerals selenium and zinc. Manganese and copper, some B complex vitamins, certain enzymes and amino acids also have antioxidant properties. Many antioxidants work together, enhancing each other’s action, which is why a varies diet that includes different antioxidants is so important.

Anti-oxidant foods
In order to slow down the signs of aging you need to include plenty of antioxidant foods in your diet. Since nutrients can be destroyed in cooking, uncooked fresh fruit and vegetables are the best sources of antioxidants. Particularly good ones include: apples, avocadoes, bananas, all berries, brazil nuts, papaya, broccoli, carrots, cherries, citrus fruits, garlic, kiwifruit, peas, plums, prunes, red grapes, tomatoes, watermelon, and many more delicious fresh foods.

Feed up on Fiber
Dietary fiber is the part of the fruit, vegetables and whole grains that our bodies cannot digest but that is essential as it ensures a speedy passages of digested food through the bowel. Waste that builds up in the bowel not only causes constipation but also brings the risk of cancer and bowel disease like diverticulosis. Fiber also helps to lower bloody cholesterol levels and helps with weight control, and plays a role in steadying blood sugar, which is important for energy levels.
Fiber is particularly important as we get older as the digestive system functions less efficiently. Try to eat 20-35 g (about 1 oz) of fiber a day.
Good sources include wholegrain cereal foods, vegetables, chickpeas, beans and lentils, seeds and fruit. Make sure you drink plenty of water to help this indigestible nutrient through your digestive system.

Check your cholesterol
The body needs cholesterol to function, but too much of it in the bloodstream results in clogged and narrowed arteries, which can lead to heart disease. Blood cholesterol tends to rise with age, through high saturated fat diet and stress. Lowering your blood cholesterol levels is paramount for good health.

Summer Beauty Hints

The most damaging factor in ageing skin is over exposure to the sun. It causes age spots, coarse wrinkles, small broken blood vessels and the skin to have a leathery texture. This type of skin ageing can be prevented. Sun can affect the skin cells and causes cell damage, but it also poses health threats including skin cancers. The effects from the sunburn may not be visible for years, but the harmful rays will have done their damage. Always protect your skin with creams and gels containing SPF (sun protection factor) dermatologist’s number one skincare recommendation.

1. Protect your exposed skin, particularly the sensitive facial skin with sunscreen containing no less than SPF 15. Anything higher than SPF 30 is not considered necessary. The extra protection afforded is minimal and additional chemicals can irritate the skin.

2. Regularly moisturise the skin of both your face and body to help retain its suppleness and healthy glow. Moisturisers replace the natural oils that dry up as part of the ageing process.

3. Cleanse your skin both night and morning. Good cleansing is essential to skin health. Without it the skin takes 25 days to rid itself of make-up and daily grime.

4. During the heat of the summer wear a hat and avoid the midday sun. Why not take advantage of skincare science available? Consider using fake tan, which correctly applied can give skin a natural looking, healthy glow.

5. Feed your skin with health giving summer fruits and vegetables full of anti-oxidants. Anti-oxidants help fight free radicals (caused by pollutants) which can harm your skin and cause premature ageing.

6. A healthy lifestyle is reflected in your skin – so be positive, keep happy and aim to be more physically active. A sense of well-being goes a long way towards delaying the ageing process.

7. Your eyes quickly show up tiredness. Not enough sleep, stress and alcohol make the circulation and lymphatic drainage sluggish around the eyes, leaving them puffy. A couple of slices of cucumber or cold, damp tea bags placed on closed eyes for 10 minutes will reduce puffiness and redness.

8. If your complexion looks sallow and dehydrated exfoliating will quickly tone and restore it. Use a scrub with tiny, gentle scuffing grains to boost circulation and give your skin a healthy glow.

9. If you intend braving the elements use a special barrier lipstick when you are outdoors to form a layer of protection from the drying effects of sun and wind.

10. Keep waterproof mascara for beach holidays or emotional moments only! Removing non-waterproof mascara is kinder to the sensitive skin around your eyes.

11. If you are a little overweight wear a good fitting, flattering 1 piece swimsuit in a stunning colour to boost your confidence. Buy a sarong to compliment it. You’ll look chic and ready to go…. Leave the bikinis to the very slim or the very young!

Breast Cancer Book – Answers at Your Fingertips

Recently I came across an excellent book “Breast Cancer – Answers at your fingertips”. Oh how I wish this sort of book had been available to me 22 years ago when I travelled my breast cancer journey alone. Sadly this book and all the other such books had yet to be written because cancer was not openly talked about that many years ago. Consequently I experienced my bumpy, sometimes frightening ride without a lot to read to prepare me for the unexpected hazards I encountered around every bend.

Happily times have changed for the better, and today bookshops are full of this type of book which means women, their families and friends, and not forgetting some men now have first class information about the disease and ways to combat it at their fingertips. To find out and arm oneself with information is the best way I know to acquire strength and knowledge which can help dispense fears and equip one to cope with the unknown. Many books are full of sound knowledge, facts about breast cancer and expert advice, and if information is given in a straightforward way it can help create a calm response to diagnosis and a positive approach to recommended treatments. Reading such books can provide answers to questions, while clear explanations, diagrams and illustrations can offer some re-assurance during the trauma of initial diagnosis.

We all experience confusion, anger, distress and fright in varying degrees, from the first signs and symptoms through to the final diagnosis of breast cancer. And irrespective of colour, class, creed or age many women will look for answers to the question “why me”? The most informative of books will have up to date advice on latest research and treatments to help guide women through the breast cancer journey. By explaining how each of us is unique and that all cancers are dissimilar, reading books can dispel unfounded myths, explain the benefits of complimentary therapies and help us understand and come to terms with, diagnosis and recommended treatment.

If you are embarking on your journey, or travelling down the road for a second time my personal tip is to read as much as you can, make a list of your concerns and keep asking your medical team questions. Take notes of advice you are given. If you are unsure of anything or have specific concerns, ask for a more thorough explaination, this will help you avoid unnecessary worry and stress. Or why not contact one of the cancer support organisations whose websites are another excellent source of information? Some hospital breast care units have specially trained cancer counsellors to help advice and support patients, so talk to them. If you are just starting out on the breast cancer journey it is so important that you digest and think through all the information you are given so you can be sure before you make important decisions. You alone must feel confident when you finally give your consent to the medical team to proceed with recommended surgery, treatment and care. Remember it is your body and you should be in control when you give them permission to start down the road.

As you make your traumatic journey you may discover a positive and unexpected benefit from your breast cancer experience. Your view of life will sharpen, and life itself may feel richer and more precious. As a survivor I know, because it happened to me and strange as it may seem my breast cancer experience enriched my life. And now I don’t intend to waste a single day of it!

Public Health Experience: Why Submit Case Study?

Harvesting Tacit Knowledge

It is generally agreed that we have neglected the knowledge derived from experience, focusing instead on the knowledge derived from the analysis of routinely collected data, stats or information, and knowledge derived from research, namely evidence.

This is a resource of vital importance and a resource that will grow. It is expected that each Public Health professional will submit a case report each year and this will be kept as a closed resource to encourage people to describe their failures as well as their successes. It is hoped that professionals will report on the projects that did not go so well as well as on those that were highly successful, for there is a proverb in management that we learn more from out mistakes than our successes. There is another proverb that says that although it is important not to re-invent the wheel, it is sometimes necessary, but what is really important is that we do not re-invent the flat tyre.


There are three general categories under which the Public Health Experience Case Studies will fall:

Health Protection

Health Protection is a term used to encompass a set of activities within the Public Health function. It involves:

  • Ensuring the safety and quality of food, water, air and the general environment
  • Preventing the transmission of communicable diseases
  • Managing outbreaks and the other incidents which threaten the public health.

Health Promotion

The process of enabling people to increase control over their health and its determinants, and thereby improve their health. 
These determinants of health could include income, housing, food security, employment, and quality working conditions.
Health Care
The diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans.

Benefits of submitting Case Studies

Everyone who submits a case report will receive proof of publication for inclusion in their development portfolio and we will think of ways in which particularly powerful case reports are rewarded. In the meantime it is in all our interests to build a powerful casebook, our interests as individuals and as a professional group.

Sometimes we can bring the change by bureaucratic authority, sometimes because we have large amounts of money at our disposal, usually these conditions do not apply. Instead we have to rely on what Max Weber called sapiential authority and the use of knowledge with confidence and authority. This in turn creates charisma, and charismatic authority is another important type of authority in which Public Health professionals have to rely.

Submitting your Case Study

To submit your case study please visit the Contact Us tab.

How to Determine Allocative Value in Healthcare

Allocative Value in Healthcare: determined by how assets are allocated to services for different purposes.

Allocative Efficiency

Allocative value, or allocative efficiency as it is also known, has until recently being largely ignored in healthcare in part because of the dominant part that the United States plays in thinking and writing about healthcare. Allocative value requires a consideration not only of institutional quality but also of the impact that a healthcare service has on the population. There has recently been good work through the Choosing Wisely Campaign but the main aim is to reduce costs, not to help decision making for a whole population. Allocative value is a hot topic when needing to make a finite sum cover a whole population.

There are three levels of decision making needed to increase Allocative value in healthcare once the decision on how much to top slice for research and education and the decision on geographical resource allocation has been made.  These three levels of allocative decision making are:

  • Between programs, for example between cancer and mental health or vice versa
  • Within program between system, for example between asthma, COPD, sleep apnoea and breathlessness within the respiratory program and
  • Within system, for example within the resources available for COPD

 The Oxford Value Improvement Programme


Tremendous progress has been made over the last forty years due to the second healthcare revolution, with the first healthcare revolution having been the public health revolution of the nineteenth century. Hip replacement, transplantation, and chemotherapy are examples of the high tech revolution funded by increased investment and, in the last twenty years, optimised by improvements in quality, safety and evidence based decision making. However there are still three outstanding problems which are found in every health service no matter how they are structured and funded: One of these problems is huge and unwarranted variation in access, quality, cost and outcome, and an analysis of unwarranted variation reveals the other two –

  • Overuse, which leads to waste, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients and often, patient harm, even when the quality of care is high
  • Underuse which leads to failure to prevent the diseases that healthcare can prevent, stroke and vascular dementia in atrial fibrillation for example, and often inequity

In the next decade need and demand will increase by at least 20 % so what can we do to tackle these outstanding problems and meet the growing need and demand?


The first step is to focus on value – on triple value The key transformation is from a focus on the quality of service for the patients treated by the individual institutions in Oxfordshire to improving value for the population as a whole and for every individual in the population with triple aims

  • Increasing personal value by ensuring that we focus on each individual’s problem as well as their diagnosis and ensuring that their values are taken into account in personalised decision making
  • Increasing allocative value by ensuring the optimal distribution of resources not only between different programmes such as the programme for people with cancer and the programme for people with mental health problems but also the population based systems within each programme for example within the respiratory health programme optimising allocation betten the services for people with asthma, those with copd and those wit hsleep apnea
  • Increasing technical value from the way the resources are used for all the people with a particular health need such as back pain, or atrial fibrillation or being at the end of life not only by delivering high quality care efficiently but by relating to all the people in need and minimising bot over use and underuse

Low quality care is low value , but high quality care may be of low value too if it does not add value for the population or the individual. The focus has to be on value


Firstly we need to continue to

1. Prevent disease, disability, dementia and frailty to reduce need
2. Improve outcome by provide only effective, evidence based interventions
3. Improve outcome by increasing quality and safety of process
4. Increase productivity by reducing cost

These measures reduce need and improve efficiency BUT we also need to increase value by

  1. Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered and relating that to the problem that bothers them most and their values and preferences
  2. Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity
  3. Ensuring that those people in the population who will derive most value from a service reach that service
  4. Implementing high value innovation funded by reduced spending on lower value interventions
  5. Increasing rates of higher value intervention eg helping a higher proportion of people die well at home funded by reduced spending on lower value care in hospital in that population

The Oxford Value Improvement Programme is focused on developing the systems, culture and skills required for all nine of these key tasks and improving the tenth factor – the morale of the people who deliver the service

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.

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)