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

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.