Is the Aim of the Health Care System to Maximise QALYs? An Investigation of ‘What Else Matters’ in the NHS

21 Pages Posted: 19 Aug 2015 Last revised: 2 Sep 2015

See all articles by Koonal Shah

Koonal Shah

Office of Health Economics; University of Sheffield - School of Health and Related Research (ScHARR)

Cecile Praet

Office of Health Economics

Nancy Devlin

Office of Health Economics

Jon Sussex

RAND Europe

John L Appleby

King's Fund

David Parkin

National Health Service South East Coast

Date Written: May 1, 2011

Abstract

Background: It is often assumed that the objective of health care is to maximise health using available resources. This is the principle underpinning NICE’s use of cost effectiveness analysis based on incremental cost per QALY gained. Yet research on local NHS decision making shows that cost per QALY is far from the only consideration. Similarly, many key national health policy initiatives appear to be driven primarily not by QALY gain, but by ‘process‐of‐care’ and other considerations. The apparent disjunction between the goals being pursued by different agencies within the health care system has potentially important implications for efficiency.

Objective: While the criteria used by NICE are well understood, the principles underpinning policy evaluation by the Department of Health (DH) have not previously been subject to any systematic enquiry. Since 2008, the DH has been required to undertake and publish Impact Assessments (IAs) identifying the costs and benefits expected from all new policy implementation. The aim of this study is to identify the benefits considered by the DH as relevant to its decision making, and to highlight implications for decision making across the NHS.

Methods: We analyse all IAs carried out by the DH in 2008 and 2009. The stated benefits of each policy were extracted and a combination of methods used to categorise these. Other DH documents were consulted for information on the means by which these benefits are valued.

Results: 51 IAs were analysed, 8 of which mentioned QALY gains as a benefit. 18 benefits other than QALY gains were identified. Apart from improving health outcomes, commonly referred to types of benefit included: reducing costs, improving quality of care, and enhancing patient experience and empowerment. Many of the policies reviewed were implemented on the basis of benefits unrelated to health outcome. The methods being used to apply a monetary valuation to QALY gains (in IA cost‐benefit calculations) are not consistent across IAs or with NICE’s stated threshold range.

Conclusions: The DH, local NHS commissioners of health care and NICE each appear to approach resource allocation decisions in different ways, based upon different considerations and underlying principles. Given that all these decisions affect the allocation of a fixed health care budget, there is a case for establishing a uniform framework for option appraisal and priority setting.

Suggested Citation

Shah, Koonal and Praet, Cecile and Devlin, Nancy and Sussex, Jonathan Mark and Appleby, John L and Parkin, David, Is the Aim of the Health Care System to Maximise QALYs? An Investigation of ‘What Else Matters’ in the NHS (May 1, 2011). Available at SSRN: https://ssrn.com/abstract=2634413 or http://dx.doi.org/10.2139/ssrn.2634413

Koonal Shah (Contact Author)

Office of Health Economics ( email )

7th floor Southside
105 Victoria Street
London, SW1E 6QT
United Kingdom

University of Sheffield - School of Health and Related Research (ScHARR) ( email )

Regent Court
30 Regent Street
Sheffield S1 4DA
United Kingdom

Cecile Praet

Office of Health Economics ( email )

12 Whitehall
London, SW1A 2DY
United Kingdom

Nancy Devlin

Office of Health Economics ( email )

105 Victoria Street
London, SW1E 6QT
United Kingdom
0044 2077478858 (Phone)

Jonathan Mark Sussex

RAND Europe ( email )

Cambridge
United Kingdom

John L Appleby

King's Fund ( email )

11-13 Cavendish Square
London, W1G 0AN
United Kingdom

David Parkin

National Health Service South East Coast ( email )

United Kingdom

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