Cost-effectiveness has been the flavour of the month in the NHS since long before there were even mutterings of a financial downturn – squeezing the most out of every penny, making sure each tax pound buys the most measurable benefit it can for patients. For over a decade, NICE has been seen by many as the international gold standard in the field, heralded for its entirely impartial, objective approach – and with NICE its faithful workhorse the QALY, which takes no prisoners and looks ruthlessly at the clinical benefit given to the patient treated, ignoring political, or sentimental pressure, or any suggestion that medical conditions might in any way be different or deserve different treatment.
Now, there is change in the air. A relatively new kid on the block is making noise that has reached even the secretive corners of Department of Health pharmacy price negotiators, and might well echo around the NHS as the ranks of commissioners undergo wholesale change for April 2013. Social values-based judgements could be poised to become all the rage.
‘Social values’ is a shorthand for ethical principles that we, as a society, supposedly find important to pick between competing needs. Solidarity, the increased value of months at the very end of life and the desire to help the very young are all examples. By contrast with cost-effectiveness, it allows the nominal preferences of a population to be considered when deciding which services to prioritise. It allows a commissioner to consider whether to invest in keeping an autism centre, which undertakes research that incidentally benefits autistic children across the country, open to all; or to invest in a new system to improve the triage of falls cases in his area which already has a large elderly population – even when both options have the same cost-benefit ratio. Indeed, it would allow the commissioner to pick the service with the lower cost-benefit ratio, on the basis either that his society placed an additional value on providing knowledge for future populations, or alternatively on meeting the needs of the greatest demographic under his responsibility. Supporters argue it allows the application of common sense and humanity to an otherwise overly rigid science. Detractors, however, would suggest that it amounts to a fudge, resulting in inefficient expenditure as a result of the failure to take tough decisions.
The move to using social value judgements is not new. NICE’s Citizen’s Council has been operational for many years. However, their application really started in the NHS with the Richards’ ‘Top-Ups’ Review, when it became clear that the value people placed on gaining a few additional months to settle their affairs when they had only a few years to live was much higher than the value an average healthy person would place on adding a few more months to their life expectancy, whatever that might be. Exceptions to the rigidity of the QALY were introduced in this limited circumstance, and new procedures were considered for orphan drugs. The concept is spreading though, with the Department of Health entering into negotiations around a value-based pricing scheme for pharmaceuticals. In its only ever stakeholder meeting on the issue, the DH made clear to patients that the process would sit entirely outside of the NICE system: this will be more than simply a tweak to the QALY methodology.
Valued-based pricing may be the ground on which the battle over values is played out, but it is worth remembering that drugs only account for some 12% of the NHS budget. The application of social value judgements has far greater application than national decision-making processes over drugs. Beyond DH drug price negotiations, there is now talk of how clinical commissioning groups (CCGs), the soon-to-be holders of NHS purse-strings, can incorporate the needs and desires of their populations into all their rationing decisions. And with this comes the chance of new ideas about valuing outcomes of care being introduced to NHS purchasers across the country.
The concept is simple – truly recognising what we want for our money, and the full benefit that the NHS can bring to the population it serves. Implementing it, and making sure that any calculations live up to the ideal, is another question entirely. The QALY has been so potent exactly because it excluded value judgements – beyond some questions over how quality of life was assessed; it used hard maths to bring about a metric that was supposedly immune to human influence. By doing so, it ducked the difficult questions inherent in applying judgements to emotive issues. Commissioning based on social values necessarily means that the NHS will buy services that do not produce direct value for money (or at least not value in the sense that we currently perceive it). The ‘years added to life and life added to years’ that we can buy will be decreased, in buying the years and life that we most want. If the ideal is to reflect what we all want though, we need to find a way of deciding what we want – and what we all want together.
How far do we go – plenty can be said for assessing the impact certain interventions have on people beyond just the patient; their families and carers should surely be considered too in terms of the ‘good’ a drug or procedure can do. But how wide do you search for benefit? And how do you decide whether we, as a society, find it more important to give a dying patient a few more weeks to say goodbye, or to provide for those who could receive their care through no other means… and exactly how much more important?
Perhaps one of the greatest worries for social-values based commissioning in the post-reform world is that clinical commissioning groups simply won’t have any background in making decisions like this. For GPs, the most basic health economics is rarely covered on medical school syllabuses, let alone the moral minefield that is ethical funding judgements. As members of CCGs square up to take on the whole host of new responsibilities, it seems unlikely that they will be taking the time to go to social philosophy school.
And it’s not just the doctors themselves that will have to work out how to properly bring society’s opinions into their decisions; as GPs start exercising their professional judgement in commissioning decisions, we can expect to see a rush of test cases before professional and regulatory bodies, as lawyers make a mint arguing how settled obligations should be applied to new situations.
Assuming we are sure we want to take a broader view of what the ‘benefit’ side of the equation is, we will still need to get to the bottom of what it is patients (and their families and carers, and the wider public) want. But not all patients value the same thing, and some are much better at shouting loudest. Whether, how and to what extent effective campaigning can shape the way society makes the judgements about what it values remains to be seen.
The academic and policy momentum to increase the use of social-value judgements is building , but adding such an intricate idea just when a whole load of new commissioning organisations get their hands on a bunch of new levers for influencing policy is going to make things interesting. The new commissioners are going to need guidance, and active leadership on this. The NHS Commissioning Board has given no indication that it is interested in driving this change; CCGs are likely to be immensely busy exploring their new remits and learning (possibly the hard way) just how to prioritise in addition to being doctors. Interestingly the only resource on how to do this seems to have come from academia, with a group sitting between UCL and KCL creating a public repository of information on previous social values-based commissioning decisions from around the world. It comes with and offer of their experience and expertise to any who are worried about how they should approach the new choices they are presented with.
With 152 PCTs handing over to 212 CCGs (at the last count), and a new line-up leading the groups, the stage seems set to allow brave new thinking into our commissioning world. The floor is wide open though for groups from all corners to start staking a claim for more social value judgements to be included – and for their preferred social values to be top of the agenda.