NEW ECONOMY

Lt.r.ci.

The QALY debate shows values and indicators are inextricably linked

The need to focus onhealth as muchas 66health care has long been [our] ambi-

by the Health Seaebry in the 1992 White Paper The Health of the Nation’, are difficult to realise. This is pdybecause of the diffi- culty of measuring exactly what is being achieved by health care. Given that the issue of health and health care is a problem for policy makers, could indiators that tell us samething about the quality of life make the task easier?

tion.” such good intentions, expressed

What is heatth? Let us be@ by considering what health (or well-being) actually means. Everyone desires good health, and most of us would favour public action to help 0th- achieve it. Prob- lemsbegin when wehave to distinguishpeo- ple in good health, who do not need help, from people who do. Consider the following: JOHN, 45, has worked as a bank clerk for

20 years. He is overweight and smokes 20 a day. When he gets home from

work each day, he does no more than eat his evening meal-prepared for himby his wife- and doze in h t of the televisionbefore mtir ing tobed. Johnvisitshis GPonce a year for a check-up. He has no diseases and does not feel ill. JANE is a singIe woman of 32. Before a

serious car accident, she worked as a journal- ist. Now she is partially paralysed and lives on her o m in a specially designed flat She receives some basic income from the compen- sation awarded after the accident, and does freehum writing. She is content & a day-by- day basis, but womes about the longer term future.

Are both in good health? If not, which one deserves priority? Finding answers to these questions involves a lot of thinking, well de- scribed by David Seedhouse (1986), from whose work the portraits above were adapted. A doctor might say Jane is more un- healthy than John because of her disability. But if a positive attitude to life is considered more important than one’s physical state, John is worse off than Jane. Them am no sim- ple solutions; one could even say that people can be healthy and unhealthy at the same time.

Political choices. However difficult it is to define good health, choices have to be made. Two key questions

0 how much of our overall economic activ- ity should be devoted to improving health how this should be distributed between different programmes - for example, be- tween the NHS (the lion’s share) and other

are:

1070-3535‘96 010020 + 05 5012.00‘0 i 1996 THE DRYDEN PRESS

A PICTURE OF HEALTH? 21

public action such as Nutrition training for the catering industry as pmposed by the Health of the Nation Task Force (Nutrition Task Force, 'Eat Wellf' Department of Health, 1994).

Such decisions must ultimately be made on political grounds because the definition of good health depends on one% personal val- ues. Indicators can never replace persrmal judgements. But it may be that they can act as useful supplements. First, we need to examine the thinking be-

hind health mdicators and their state of devel- opment so far. Undqinning all work in this area is the idea that health is a commodity that can be valued. The next problem is choosing a measurement scale. The simplest is the length of life, or the number of years of extra life gained by health care intervention.

We can use this approach to monitor over- all health by using average life scpectancy. Between 1976 and 1988 this increased by 3 years in men and 2.6 years m women. So far, so good. The problem is quality of life. Over the same period, the average length of life endured with 'chranic disability' rose by 21 years in men, and by 2 5 years in women (On the state of public Health, 1990). So most of the extra years gained were not completely healthy ones. This puts quite a differ- ent gloss on the

To be able di- rectly to compare health services which extend length of life with those that im- prove quality of life, we need a measurement scale to cover both.

figures.

Valuation of health scales In the 197Os, when expenditure on hospital

sure tomakechoicesbetween different types of hospital care, the work of Rachel Rosser formed the basis for the development of Quality Adjusted Life Years (QALYs), the measurement most widely used today.

Rosser fhst defined a number of health states that adequately describe the full range of hospital patients. To consider every nuance was impossible. Instead there were just two dimensions: disabilityanddistress. Disability was stated as one of eight points, ranging from normal function to total unco~lscious- ness; and distress as one of four levels: none, mild, moderate or severe. Combining these two dimensions gave 29 different states of ill- ness (three less than might be expected be- cause distress cannot be quantified when a

Next,7Opeople wert?askedto&thediffer- ent 'marker states', for simplicity, the six m the Table Each persan considered the states, and was asked: "Howmanytimesmoreillisaper- son described as being m 'state B/disability

services W ~ S rising fast and there W ~ S PIPS-

person is u n c d o u s ) .

Marker states used in valuation exemise and dre median scores giventothembyi-

7 2

Mcdip, scm? - 2.00

I3.M

13.03

13.00

a7.20

497. I4

22 NEW ECONOMY

2/distxes 4 (B-

with ’state A/ disability

1-3)””. Inter view- had to assumethatall the descrip tions were of people of the - age, a d thatallcarried the - Prog- nosis (chanc~ of a return to full health, given the resoum? ahcation). Also, they had

allocated to the relief of the patients m the

swer. So, if state 8 2 4 was judged to be three

muchmoneywouldbeusedtobringapatient mstateB-24backtogoodhealthcompared to one in state A-1-3. Each of the six states m the Table were considered in this way. Once the six marker states had been positioned on the scale, the other 23 states were med mby the interviewees. The relative ranking, or score, is a ratio m the form of how many more times (double, treble, ten-fold, etc) * sources should be a b cated to relieve a pa- tient in state X com- pared to someone in perfect health.

The median scores obtained for each of the six marker states are shown in the right hand column of the Table (on the previous page). The 70 people mter-

2-4)‘ wmPa=d

l/distress 3(A-

to imagine that the amount of Iesoums to be

different states was proportional to their an-

times than mte A-1-3, h times as

viewed consisted of seven groups of 10 peo-

ple from dif- ferent occupa- tions. As the bar Chart shows, these s u b g r o u p s

in their valu- ation of marker states. The Chart shows the

C, but the les-

Not shown, but equally

important, was a large variation between in- dividuals within the subgroups. Here is one of the biggest problems with hedth indica- tors: the lack of agreement between different raters. Giving a numerical score to an imagi- nary state of health, not set m the context of an individual life, is lmfarmkar .. andartificial.Itis not surprising that the valuations are vari- able.

varied greatly

range on State

sonisgeneral.

From health states to QALYs Leaving this problem aside, how can health state valuations be used to help prioritise health care?

Take hip joint re-

formation is needed about the ’typical case’ or the average of a rep- resentative series. In the simplified example shown in the Chart, wearing out of the hip jomt begms at point H (say 65). Until then,

quality of life has been near perfect, as shown by the line OA, which scores just under 1 in the ‘health status index’. (The health status

placement surgexy. In-

A PICTURE OF HEALTH? 23

index is a transformation of the scorn discussed earlier, such that perfect health scores 1 and death scorn 0.) After 65, health status depends on whether or not an operation is per fomed. Without the operation, qual- ity of life will gradually deteriorate as the person becomes more disabled (line AX, Chart). Eventually, the per scm dies (point X). With an operation, quality of life is briefly impaired (shownbythenickintheline)butthen returns to near n o d Because the

QALY Loape Tdo

person is mobile and free of p& they might be expeded to live longer - until point Y. Ad- justment of the post-operative pmfik can take account of the probability of death or other serious complications of the operatim itself. The shaded areabetween the two lines repre- sents the quality adjusted life years gained by operating. This canbe related tothe cost of the surgery and afterare, and so give a 'cost per QALY' for hip replacement surgery.

constmcted for any health care interventions for which data on health status of a typical case with and without the intervention are available. All these interventions can be or- dered by their cost per QALY, producing a league table, as shown in the Table.

If you believe in the QALY league table, ra-

compdingdiagramscan,intheory,be

tionalpriority-seltingistheneasy.Thetopin~ vention (ch01Wl testing and dieting) deliv- ers the most quality adjusted life years per paund,andsoshwldbeperformed~~every a~riatecasehasbeentreated.Nextbestis thesecondinrank,whichshouldbeprovidedin the same way, and so on down the table tlntil healthcareresoufiesan?exhausted.

Problems with the QALY approach There are some obvious problems which spring from the way QALYs are worked out. These are:

Simplifying all descriptions of health to two dimensions, disability and distress Lack of rating agreement by between dif-

ferent groups (nurses, patients, and so on) 0 Individual rating variation within groups 0 Using a 'typical case'; there is ao such

PerSon 0 Etwurhg costs have been measured in the

same way throughout the league table. Even if all these difficulties couldbe overcome, or dismissed, there are more bdamental problems. First, the QALY approach treats eachyearof (quality adjusted) life gainedas equal. One year of extra life for a child who wouldohenme * dieimm*telyiscas the same as two years of 50 percent quality in an older person who subsequently recovrs andthenleadsafulllife.Thevaluationtakesno account ofthe point m the disease process at whichthegaintakesplace.Tomostpeoplethis would seem tobe unfair.

Second is the problem of ageism. Interven- tions in childhood may lead to QALY gains lasting 50 years or longer, but an apparently similartmatmentinaneldedypemmcannever add up to so much because they will not live as long. But does being old mean someane is not entitled to the same degree of improvement in their well-being as a younger person? Third,QALYsweredesignedtojudgehospi-

tal output rather thancommunity care or wider healthplmnotion Yet m thenext50 years and beyond, them are going to be inmasing num- bers of elderly people who need support m the mnmunityratherthanhospitalcare. Qualityof

vacy, dignity and choke How can thesebe fit- life in this context means inde!pe!dence, pri-

74 N E W ECONOMY

bed mto the disability distnss matrix? tain their general purpo~e. TWO proposed al- tematives are Healthy Year Equivalents

The alternatives (HYEs)andSavingAYoungLifeEquivalents (SAYES). These new scales have some advan- Given the impedecth of QALYs, we should

laok for oth& ways to make policy choices.

The first optionis toaccept the principles of the present

two big questions previously

The first lT&rred to the pm

arrangements but try to im- prove the details. How are the

described being answered?

portion of gross national

"The trouble with death rates i s their

narrowness; good health i s

clearly m m than the avoidance of

death."

product we &vote to health. his is w y detexmjned by the Treasury, using an Effi- ciencyhdex toagreeNatidHealth Service expenditure. This relates changes m activity (outpatient attendances, for example) to changes m cost. There is no consideration of whethersuchinaeasedactivityactuallyleads to m d health, or of whether historical levels form the correcf badhe. Answers to the second question - how expenditwe is to bediStlibUtedbetw~differentprogrammes

changesbetween areas may occur fromyear - d-d W y recent history. Margh.ral

to year. Such choices are made at local rather than national level, an advice of doctors and other health care pmfessionals. The recent NHS reforms supposedly give more say to other groups with a legitimate interest, such as patients;but m my opinion the real effect is small.

The second option is to try other health indicators. This has already begunm the areas of coronary heart disease and strokes, cancers, mtd illness, accidtnts, and sexual health. Targets havebeen set, many of which are ex- pressed as reductions in mortality rates.

choices,but at least they providea mechanism for monitoring progress. The trouble with deathratesistheirnarr0wness;gdhealthis clearly more than the avoidance of death.

A third appmach is to modify QALYs to address their problems, while seeking to re-

T h e cannot in t h d v e s idom policy

tages, but sti l l suffer from variationsbetweenratexsand the problem of the 'typical case'.

Conclusions

tain good health will always Policy to produce and main-

d y on political rather than technical matters, because

health is so complicated to define. Simple health mdicators, such as mortality rates, are of limited use because of the namw defini- tion of health they presuppose. More com- plex indicators, such as QALYs, still rely on a fairly limited concept of health,.and are much less reliable. More reseafih is needed to overcome their problems and develop new techniques. Meanwhile, we must fall back on existingpolicymakingmethods,andlisten to the people who deliver and receive health

Nevertheless, QALYs am an important de- velopment They suggest a new way of think- ing about the output of health care. New and highly speclalised medical treatments can be compared to simple primary care, so making hospital coIlsultanfs more accountable. Simi- larly, the health output of doctors' work can be compared to that of nurses or health edu- cationalists. Some health economists have ar- gued that this approach will mcover new o p portunities to improve the nation's health without costing more money, by streamlining medical practice using economic output crite- ria. These indicators could revolutionise the medical profession, if their wealcnesses were overcome. The reader is left to judge whether this holy grail can ever be reached

care.