Resource Allocation And QALYs Flashcards
NHS cost increases
- 5% of GDP in 1949-1950
- 2% of GDP in 1999-2000
- 5% of GDP in 2009-2010
why are NHS costs increasing faster than inflation?
increasing longevity
changing demographics
changing lifestyles
increase in certain medical conditions - T2D, obesity
change in public attitude towards healthcare utilisation
change in government policy
cumulative effect o cost inflation because of medical technology advances
healthcare labour costs
prescription costs 12% of budget
how can the NHS save costs
efficiency savings
better public health
generic prescriptions and collective bargaining for goods
restructuring - arguable
if we increase healthcare budget as % of GDP then money is taken from education, social care, etc - this would decrease goodness derived from other government funded services. therefore tailing is already with us and is inevitable.
resource allocation by merit
attractive at face value but has significant problems, for example how do we decide what an individual deserves? income/tax nor equivalent to merit as people may pay low tax but contribute more such as carers.
much/most ill health is due to lifestyle issues such as smoking and diet, and so there is a slipper slope in saying that some dent deserve certain healthcare items.
healthy people may just be lucky!
it is important to remind people of their responsibility for their own health.
remember that pensioners have pain into the system over their lifetime and should not face discrimination.
justice, social solidarity ad the traditional hippocratic oath implies that HEALTHCARE SHOULD BE ALLOCATED ON THE BASIS OF NEED - DISTRIBUTIVE JUSTICE
resource allocation options
merit
what someone has paid into the system
personal responsibility
equity and economics
NICE attempt to run fair and transparent system
new treatments approved on the basis of clinical and cost effectiveness
financial costings are relatively unproblematic, although there is a question of immediate cost to provide treatment
the greatest difficulty lies with QALYs
QALYs problems
setting a threshold for a maximum cost per QALY gained impacts the young less. this is how NICE currently operates.
elderly people, and those with chronic conditions, or multiple conditions are disadvantages due to their technical inability to benefit as much as young and relatively healthy members of society
NICE is hugely influential
concept of ‘fair innings’
Mary Warnock said dependent elderly are ‘wasting the resources of the NHS’
John Hardwig - “duty to die becomes greater as you get older”
Age alone is not necessarily related to capacity to benefit from the NHS. QALYs are flawed in that the elderly are discriminated against
Need for health
John Harris said ‘the need for healthcare cannot legitimately be equated exclusively with one measure of the degree to which healthcare can benefit the individual’
Fisher and Gorman have ten measures of need
Fisher and Gorman 10 measures of need
1 - greater urgency
2 - greater likelihood to benefit
3 - likelihood of greater benefit
4 - likelihood of lesser burden from treatment
5 - lesser likelihood of harm from treatment
6 - likelihood of greater harm without treatment
7 - likelihood to gain the same benefit from less treatment
8 - likelihood to need less treatment
9 - lack alternative method to satisfy need
10 - greater likelihood to infect others if untreated
potentially can add 11 - kind of intervention required, with basic care more needful
QALY criticisms
welfare not the only value to be put into the equation (needs vs benefits)
QALYs are unjust because they do not take into account who is experiencing them
Calculation is problematic if not impossible. at best, it is highly subjective.
ageism - elderly are not discriminated against because they are old, but because they have less years expected to live. young people with life-limited illnesses are discriminated against in the same manner.
Rawls - veil of ignorance
imagine looking down on different societies knowing that you have to enter one. you do no know what you’re social status will be or how heathy you will be.
which one do you choose?
should join the one where the lowest social groups have the highest care - this is not necessarily the most equal society. inequality may bring the standard up for the poorest - trickle down economics.
as applies - veil of ignorance vs QALYs - hernia vs kidney disease. treating one hernia provides one QALY. kidney disease treatment provides 50 years. you can treat 100 hernia patients or one kidney patient. QALYs would favour hernia treatments for 50 people, Rawls might favour kidney replacement.
criticisms fo Rawls
some people would gamble on not being the poorest in society.
maximum benefit for the worst off should not be the only principle. it is unclear how to balance this vs other principles. if the worst off benefit only a little, should we still prioritise them over others?
a needs based multi principle approach
to each according to need - first principle of distributive justice (most sick = most need)
respect principles of no unjust actions, no discrimination (race, age, gender)
virtue of prudence - be flexible with allocation - changes with urgency of condition, flexibility of patients and clinicians etc
provide a voice for the voiceless
ensure funding system works for the many, not the few
