How do we make decisions in health care? How should we?
In making decisions about health care allocation, and in particular whether a new drug should be made available on the NHS, current procedures examine the cost-effectiveness of any new drug or procedure, considering the health gain it provides for the cost.
An essential part of this process is to assess health improvements in terms of the QALYs they yield. Currently a ‘time-trade-off’ method is used in which members of the public are asked how much life-expectancy they would be prepared to give up in order to be cured of particular illness. This is then used to provide valuations of all relevant health states.
Is this the right process? It certainly raises many questions.
One concerns the measurement of QALYs. First of all, is it right to concentrate on the preferences of members of the public, rather than patients, who have actually experienced the condition, or professionals who are experts? Secondly, is it right to concentrate on preferences rather than experience or capability measures? Third, when there is disagreement in judgement or preference (as there always will be) how should different views be combined into a single measure.
These are not merely abstract questions.
For example, it is said that members of the public regard mental illness and chronic pain as less severe than those who suffer from them, yet regard physical mobility as more problematic than is judged by those who do suffer from such restrictions. In such cases do patients have more insight into the difficulty of their conditions, or do they simply ‘put a brave face on it’ and adapt to their condition? For another example, economists will tend to average differences, but another approach would be to use deliberative methods. These could lead to very different outcomes.
Therefore, it appears that different measurement methods could lead to different drugs and procedures being made available on the NHS and hence these questions are capable of making critical differences to people’s lives.
So, are we making the right decisions? Is it possible to make better ones?
Jo Wolff is the Blavatnik Chair in Public Policy at the University of Oxford.