The issue of how to best determine the value of treatments and priority areas for healthcare funding has re-entered the spotlight following the publication of two papers in the British Medical Journal that separately question the methods used for drug rationing in the NHS.

In one paper, a team from Imperial College London, led by Professor Paul Dolan, voices concern over how the drugs cost watchdog for England and Wales - the National Institute for Health and Clinical Excellence - calculates the value of treatments intended for use on the NHS.

The Institute currently bases its cost effectiveness decisions on the QALY – quality adjusted life year – which is calculated with the aid of the general public’s opinion on how many years of life they would trade to avoid different states of health. However, the researchers argue that the preferences of healthy people asked to consider hypothetical health scenarios could be very different to those of actual patients.

Moreover, they point out that fundamentally “strength of preference itself is often a poor guide to actual experience”. Healthy members of the public being asked to consider moderate pain could easily imagine that it would dominate their lives when, in real terms, this is unlikely, while, on the other hand, patients asked to imagine having their health problems alleviated will probably only focus on what life is like when they are actually attending to their health state, and so “preferences are problematic from whomever they are elicited”, the researchers conclude.

In addition, preferences gathered from the general public could be seriously skewed by individuals’ emotional responses to different health states. For example, the most severe of these are likely to evoke fear, “but accounting for fear is quite separate from accounting for the real losses from a given health state”, the authors explain.

In order to address these issues, the researchers suggest a measure of subjective wellbeing – including an assessment of happiness and life satisfaction and information on broader topic such as marital status – of the individuals (such as patients, carers or relatives) affected by a certain condition, to help get a fairer and more realistic idea of the impact of certain health conditions and the degree of suffering treatments address, thereby leaving decision-makers in a better position to dish out resources more effectively.

“Most of us recognise that NICE has to take account of quality of life and length of life gains when judging the relative cost effectiveness of different interventions [but] subjective wellbeing provides us with a means of valuing the real reduction in suffering that health technologies bring,” the authors stress.

Utility values
Another study, carried out by researchers at the Universities of Birmingham and Cardiff, compared the two methods currently used to calculate ‘utility values’ for different health states - one using the responses of healthy members of the public and the other those of actual patients - which policy makers rely on when making decisions about the distribution of healthcare funds.

Echoing the assertions made by Dolan and his team, the analysis found significant differences between the responses of hypothetical patients to ‘real’ ones. Those asked to imagine a health state “produce consistently lower utilities (worse recorded health)” than those actually experiencing it, and so the researchers warn that depending on input from healthy members of the public could result in “fewer resources being allocated to life saving treatments”.

Publication of the findings comes hot on the heels of a big review by Sir Ian Kennedy of how NICE appraises treatments for the NHS, which makes several recommendations for change including the addition of some social values to the current process.