Two things strike me on this.
Firstly there is a real and important lay interest in the outcomes of "extra" investment substantially over and above infltion for wages and equipment: and perhaps a not ungrounded and recurrent concern - from Nye Bevan onwards -about diminishing returns from expanded NHS investment.
The second is the time scale issue. I'm a public health practitioner not a health economist, but would point out that the health outcomes being measured in the the last three rolling years represent, in some part, the fruits of decades of health eductation and promotion, some NHS funded, social, political and economic change - some of which such as much tobacco control lobbying was NHS funded. All of which impact on QUALYs, and the last three years of outcomes.
One of the problems and disadvantages of a politically directed national health service is its problem in thinking and acting for outcomes beyond terms of office at best, and financial years at worst. Insurance-led programmes can think and act in acturial timeframes. It would be great if health economics could support and encourage politicians to be as imaginative as insurance salesfolk.
Mike Hughes
>
> From: John Appleby <[log in to unmask]>
> Date: 2007/03/27 Tue PM 02:22:45 BST
> To: [log in to unmask]
> Subject: FW: QALYs produced by NHS
>
> Richard
>
> well, i still maintain it's not a silly question! first, as i said, while an implication of the question is the 'NHS vs no NHS' issue, that isn't what I was interested in. And second, wrt the public, in fact I think they are actually interested not in what the extra money has produced in health terms (how ever measured) but what the total has produced...and not because they are interested in what health would be without an NHS, but because they want to know what the NHS has produced with its whole budget - particularly as it has grown substantially over the last few years. They do not necessarily assume that the total last year was spent to maximum effect and that therefore they should only be interested in the additional amount this year...
>
> re the york work, what PCTs spend in one year matches what trusts have to pay in terms of producing their output. The fact that some input costs increased from one year to the next therefore means that the spend figures york used in their calculations have these higher costs (ie 'waste' according to some) built into the single year's data they used, no? The total wage bill in any one year may be fixed, but the total for that year is the result of, amongst other things, higher pay.
>
> I agree about the problems with timing between PCT spend and the population health effects.
>
> OK, back to some work!
>
> John
>
> John Appleby
> Chief Economist
> King's Fund
> 11-13 Cavendish Square
> London W1G 0AN
>
> Visiting Professor, City University
>
> T: 0207 307 2540
> M: 07831 638774
> F: 0207 307 2807
>
>
>
> ________________________________
>
> From: Richard Cookson [mailto:[log in to unmask]]
> Sent: 27 March 2007 12:13
> To: John Appleby
> Subject: RE: QALYs produced by NHS
>
>
> I'm not sure you can argue that re: 2, for 2 reasons, though it merits further thought. First, the York work looks at cross-sectional variation in spending between PCTs for a single year (2004-5). It does not look at change over time between 2003 and 2004. So it doesn't account for waste on general wage and price inflation that affects _all_ PCTs equally - it takes a fixed set of wages and prices for a given year and looks at variations in spend between PCTs represent variations in real resource use. Second, the York work uses death rates averaged over a three year period 2002-5. These life year gains thus in fact relate to spending done in the "lean" years of the late 1990s and early 2000s, though not measured in the study - they have to assume that PCTs are some sort of equilibrium, though they don't fully tease out the implications of this assumption e.g. does this mean that if they spend x pounds more now then they must have spent x pounds more then, or x% more, or what?
>
> I agree that what the NHS has gained from the extra spending 2003 to 2004 is a sensible question. But I maintain that what the NHS has gained from zero spending to current spending is a silly question!
>
> R
>
> -----Original Message-----
> From: This is a closed list of the UK Health Economists' Study Group (HESG) [mailto:[log in to unmask]] On Behalf Of John Appleby
> Sent: 27 March 2007 11:53
> To: [log in to unmask]
> Subject: Re: QALYs produced by NHS
>
>
> Thanks Richard!
>
> 1. Yes, of course (to the curve)....but where is the NHS on that curve now?
> 2. The York cost per LY estimates use 2004/5 data (as far as i remember) and would i guess subsume the fact that some NHS money was 'wasted'. ie without waste, then the cost per LY would be lower.
> 3. I didn't have any counterfactual in mind. What i was interested in was any attempt anyone had made to estimate the change in health of the population as a result of change in investment in the NHS as part of work i'm doing with derek wanless looking back at the assumptions he made about productivity change in the NHS.
>
> As to the silliness of the question, well, i'm not sure you're right. From the public's point of view, the question 'where's the money gone?' really deserves an attempt at an answer which goes beyond simply saying 'into doctor's pockets and a bit more activity'.
>
> john
>
> John Appleby
> Chief Economist
> King's Fund
> 11-13 Cavendish Square
> London W1G 0AN
>
> Visiting Professor, City University
>
> T: 0207 307 2540
> M: 07831 638774
> F: 0207 307 2807
>
>
>
> ________________________________
>
> From: Richard Cookson [mailto:[log in to unmask]]
> Sent: 27 March 2007 11:32
> To: John Appleby; [log in to unmask]
> Subject: RE: QALYs produced by NHS
>
>
> I suspect the Maynard-Jefferson estimate of 42 multipled by 3.14 is more accurate ("ask a silly question!")... but I have good news, bad news and even worse new for you John.
>
> Good news: every health production function that I have ever seen is curvy. If we assume diminishing marginal returns, then these total QALY gain estimates are lower bounds - since the first billion pounds spent generates even more QALYs than the last billion.
>
> Bad news: as you have shown, some of the extra spending was frittered away on wage and price inflation - i.e. money gains for doctors and shareholders, rather than QALY gains for patients.
>
> Even worse news: if we didn't have an NHS, where would be be? The USA! Which spends even more on health care so presumably gains even more QALYs. So in fact, compared to the realistic alternative, the NHS is robbbing us of QALYs! Your comparator (of zero health care spending) is impossible, hence your question is silly.
>
> R
>
> -----Original Message-----
> From: This is a closed list of the UK Health Economists' Study Group (HESG) [mailto:[log in to unmask]] On Behalf Of John Appleby
> Sent: 27 March 2007 10:46
> To: [log in to unmask]
> Subject: Re: QALYs produced by NHS
>
>
> Good news, QALY fans, the answer (thanks to Alastair Fischer at NICE) to the question does not take NICE's £20k-£30k per QALY range, but uses the recent calculations by Pete Smith and colleagues at York of a cost per life year gained for cancer and circulatory diseasea (based on the DH national Programme Budget data (see http://www.york.ac.uk/inst/che/pdf/rp24.pdf.))
>
> Using this PCT spend data and variations in population health measures (mortaility), they suggest a cost per life year of around £13k for cancer spending and around £8k for circulatory disease spending. Total English NHS cancer spend in 2004/5 was around £3.7 bn, so LYs produced = 284,000. Circulatory spending was £6 bn, so LYs produced = 750,000.
>
> For the whole of the UK NHS spend in 2004/5 of £82.5 bn, assuming that cost per LY for all activities is somewhere between a pretty low number and a fairly high number - let's say, £13,000 on average....the NHS produces around 6.4 million LYs per year. And lastly, assuming that these LYs are not all of perfect quality (say, 0.9), then, quality adjusted life years produced by the UK NHS in one year will be of the order of...5.8 million (about 1.2 months per head of population).
>
> And in terms of what we got for the extra £7.8 bn spent on the UK NHS between 2003/4 and 2004/5, this suggests around 540,000 QALYs.
>
> So, the next question is: what proportion of this increase in QALYs could be attributable to improvements in the quality as opposed to the volume of health care?
>
> john
>
>
>
>
>
> John Appleby
> Chief Economist
> King's Fund
> 11-13 Cavendish Square
> London W1G 0AN
>
> Visiting Professor, City University
>
> T: 0207 307 2540
> M: 07831 638774
> F: 0207 307 2807
>
>
>
> ________________________________
>
> From: This is a closed list of the UK Health Economists' Study Group (HESG) [mailto:[log in to unmask]] On Behalf Of Fordham Richard Dr (MED)
> Sent: 27 March 2007 08:22
> To: [log in to unmask]
> Subject: Re: QALYs produced by NHS
>
>
> Gentleman gentleman,
>
> If the NHS is spending £60bn of taxpayers money presumably in the cause of improving or saving lives then then assuming it does this 'efficiently' at the marginal rate of transformation of 30,000/QALY then it must be producing about 200,000 pa. Of course, 42 might be the actual answer..
>
> Regards,
>
> Ric
>
>
> ________________________________
>
> From: This is a closed list of the UK Health Economists' Study Group (HESG) [mailto:[log in to unmask]] On Behalf Of [log in to unmask]
> Sent: Tuesday, March 27, 2007 7:34 AM
> To: [log in to unmask]
> Subject: Re: QALYs produced by NHS
>
>
> You have all forgotten to divide it by 3.14........scandalous!
>
> Dr Tom Jefferson
> Via Adige 28a
> 00061 Anguillara Sabazia
> (Roma)
> Italy
>
> www.attentiallebufale.it
> Tel/Fax ++39 06 999 00 989
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>
>
> -----Original Message-----
> From: [log in to unmask]
> To: [log in to unmask]
> Sent: Mon, 26 Mar 2007 7.07PM
> Subject: Re: QALYs produced by NHS
>
>
> Plus or minus?
>
> >>> Alan Maynard <[log in to unmask] <javascript:parent.ComposeTo("akm3%40YORK.AC.UK", "");> > 03/26/07 5:12 PM >>>
> Forty two?
>
>
>
> On Mar 26 2007, John Appleby wrote:
>
> >Any even half-evidenced guess as to the total number of QALYs the NHS
> >produces each year?
> >
> >John Appleby
> >Chief Economist
> >King's Fund
> >11-13 Cavendish Square
> >London W1G 0AN
> >
> >Visiting Professor, City University
> >
> >T: 0207 307 2540
> >M: 07831 638774
> >F: 0207 307 2807
> >
> >
> >
>
>
>
>
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