John Appleby

NICE's cost effectiveness threshold.

How high should it be?

Do patients always prefer quicker treatment

The London Patient Choice Project (LPCP) was established to offer NHS patients more choice over where and when they receive treatment, and to reduce waiting times. The LPCP offered those patients waiting around 6 months for elective procedures a choice of treatment at an alternative NHS or private hospital, or treatment at an overseas hospital.The aim of this article is to investigate the following questions regarding patients’ response to choice: (a) What are the factors that patients consider when deciding whether to accept the alternatives they are offered? (b) What is the relative importance to patients of each factor when making their choices, i.e. what trade-offs are patients prepared to make between time waited and other factors? (c) Are there any systematic differences between subgroups of patients (in terms of their personal, health and sociodemographic characteristics) in their response to choice?Patients’ preferences were elicited using a discrete choice experiment. Patients eligible to participate in the LPCP were recruited prior to being offered their choice between hospitals and each presented with seven hypothetical choices via a self-completed questionnaire. Data were received from 2114 patients. Thirty percent of respondents consistently chose their ‘current’ over the ‘alternative’ hospital. All the attributes and levels examined in the experiment were found to exhibit a significant influence on patients’ likelihood of opting for an alternative provider, in the expected direction. Age, education and income had an important effect on the ‘uptake’ of choice. Our results suggest several important implications for policy. First, there may be equity concerns arising from some patient subgroups being more predisposed to accept choice. Second, although reduced waiting time is important to most patients, it is not all that matters. For example, the reputation of the proffered alternatives is of key importance, suggesting careful thought is required about what information on quality and reputation can/should be made available and how it should be made available to facilitate informed choice.

Patient choice in the NHS

Having choice may not improve health outcomes

Measuring the performance of health systems: Indicators still fail to take socioeconomic factors into account

Reviews p 248 It seems that the whole world is suddenly talking about measuring the performance of health systems. Last month the World Health Organization published its findings from a comparative study of healthcare systems.1 This time it is the turn of the Department of Health in England, which last week published the results of the second round of performance indicators for 99 health authorities and 275 NHS hospital trusts.2 Unlike last years figures, these data will inform and shape key aspects of the governments plan for the NHS, which will be published next week. The main message of the latest performance indicators is that health in England is continuing to improve. However, there is also compelling evidence of variation in health and healthcare performance between areas and between hospitals. For example, the proportion of patients waiting less than two hours to be admitted after attending an …

Application of patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery in England

Objectives To demonstrate potential uses of nationally collected patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery. Design Cost-utility model populated with national PROMs, National Reference Cost and Hospital Episodes Statistics data. Setting Hospitals in England that provided elective inguinal hernia repair surgery for NHS patients between 1 April 2009 and 31 March 2010. Participants Patients >18 years undergoing NHS-funded elective hernia surgery in English hospitals who completed PROMs questionnaires. Main outcome measures Change in quality-adjusted life year (QALY) following surgery; cost per QALY of surgery by acute provider hospital; health gain and cost per QALY by surgery type received (laparoscopic or open hernia repair). Results The casemix-adjusted, discounted (at 3.5%) and degraded (over 25 years) mean change in QALYs following elective hernia repair surgery is 0.826 (95% CI, 0.793–0.859) compared to a counterfactual of no treatment. Patients undergoing laparoscopic surgery show a significantly greater gain in health-related quality of life (EQ-5D index change, 0.0915; 95% CI, 0.0850–0.0979) with an estimated gain of 0.923 QALYS (95% CI, 0.859–0.988) compared to those having open repair (EQ-5D index change, 0.0806; 95% CI, 0.0771–0.0841) at 0.817 QALYS (95% CI, 0.782–0.852). The average cost of hernia surgery in England is £1554, representing a mean cost per QALY of £1881. The mean cost of laparoscopic and open hernia surgery is equivocal (£1421 vs. £1426 respectively) but laparoscopies appear to offer higher cost-utility at £1540 per QALY, compared to £1746 per QALY for open surgery. Conclusions Routine PROMs data derived from NHS patients could be usefully analyzed to estimate health outcomes and cost-effectiveness of interventions to inform decision-making. This analysis suggests elective hernia surgery offers value-for-money, and laparoscopic repair is more clinically effective and generates higher cost-utility than open surgery.

Reducing waiting times for hospital treatment: lessons from the English NHS

In recent years, the English NHS has achieved substantial reductions in waiting times for hospital treatment. This paper considers first whether the data used by the Government provide an accurate description of changes in waiting times and identifies some of the limitations of the measures used. It then attempts to identify how reductions have been achieved. It argues that some features of central government policy have been important - such as the use of targets - others, such as the introduction of new private sector capacity have not. It also shows that changes at local level have been critical to achieving the recorded improvements, but the precise impact of these is hard to identify.

Is the aim of the English health care system to maximize QALYs

Objectives: To compare the types of benefit considered relevant by the English Department of Health with those included by the National Institute for Health and Clinical Excellence (NICE) when conducting economic evaluations of options for spending limited health care resources. Methods: We analysed all policy Impact Assessments (IAs)carried out by the Department of Health(DH)in 2008 and 2009. The stated benefits of each policy were extracted and thematic analysis was used to categorise these. Results: 51 Impact Assessments were analysed, eight of which mentioned quality-adjusted life year (QALY) gains as a benefit. 18 benefits other than QALY gains were identified. Apart from improving health outcomes, commonly referred to benefits included: reducing costs, improving quality of care, and enhancing patient experience. 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 cost-benefit calculations) are not consistent across Impact Assessments or with NICEs stated threshold range. Conclusions: The Department of Health and NICE approach resource allocation decisions in different ways, based upon overlapping but not congruent considerations and underlying principles. Given that all these decisions affect the allocation of the same fixed health care budget, there is a case for establishing a uniform framework for option appraisal and priority setting so as to avoid allocative inefficiency. The same applies to any other national health care system.

Does poor health justify NHS reform

Andrew Lansley claims radical NHS reform is necessary to drive up the UK’s poor health outcomes compared with Europe. But is our record really so bad, questions John Appleby?

The credit crisis and health care

With the current financial turmoil affecting the cash flow of governments, business, and individuals, John Appleby assesses the likely effect on the NHS

Measuring performance in the NHS: what really matters?

Encouraging the efficient use of NHS resources is vitally important for patients and doctors. Inefficiency means that money is wasted, but more importantly it means that the opportunity is lost to save lives, avert pain, and provide care to those in need. In a system as large and as complex as the NHS, however, actively promoting efficiency through the design and use of incentives is a difficult task. Two recent attempts to grapple with efficiency were the implementation of the internal market (which relied on supply side competition within the NHS to drive down costs) and the combined monitoring and measurement of performance targets known as the purchaser efficiency index (which was a demand side management tool aimed at encouraging health authorities to provide an incentive for purchasing efficiently provided services).1 Although the new NHS white paper has retained the split between purchasers and providers, the competitive thrust of the internal market has been abandoned.2 And, although the purchaser efficiency index has also been jettisoned, the annual requirement for health authorities to make efficiency savings of around 3% a year has been retained. The NHS white paper strongly criticised these mechanisms, arguing that the internal market increased administrative costs, fragmented decision making, distorted incentives, and promoted inequality.2 The efficiency index—a ratio of changes in activity to changes in financial inputs—was criticised for being narrowly focused and providing perverse incentives.1 3 4 What should replace these performance measures, and are the proposed solutions radical departures or simply tweaks at the periphery? #### Summary points The national reference costs database and indices provide a first step in describing and understanding variations in costs between NHS trusts There are serious drawbacks to the quality and coverage of the data used to compile the unit costs Much of the variation in overall costs …