101 Apt Aphorisms for Health Economists

Health economics is not a special kind of economics, it’s merely a special application of it.

Good health economics needs vision more than description, imagination more than enumeration.

Inter-disciplinary research on health topics is much too important to be left to those who have failed in the mainstream. So is multi-disciplinary research.

Learning health economics without learning economics is like learning to ride without the bike.

Health economics embraces two hard-to-reconcile cultures: one as a sub-speciality in economics, the other as a supplement to pharmacy or epidemiology. They have some things in common.

Mike Cooper and I were troglodytes. In those days (1960s) we worked in an intellectual cave.

Michael Hymie Cooper (1938-2017) was a pioneering English health economist of the 1960s. First at Exeter University, later at Otago University in New Zealand.

In the early days of health economics, one had only to sneeze and they would publish it.

The early debate between “marketeers” and the “anti-marketeers” was initially centred on the question of whether health care was so very different from other goods and services that government provision and finance were necessary. The anti-marketeers said yes, emphasizing special characteristics; the marketeers attempted to show how markets could cope efficiently with each special feature in turn. However, neither side had satisfactory descriptions of the objectives of a health system. The former lacked one because in the never-never land of the perfect market, with which socialized systems of health care were usually compared, no such specification was needed: the outcomes would be whatever individuals wanted and were prepared to pay for. The anti-marketeers lacked such a description because they talked of a world in which men and women of good will set about meeting the reasonable needs of their clients, avoiding such troublesome questions as the meaning of “needs,” what was “reasonable,” who the “clients” should be, and how such “needs” might best be met. Here, then, was an agenda for health economics.

The distinctive essential syllabus of Health Economics: health in the social welfare function; health as capital; the demand for health; the demand for health care; agency; supplier-induced demand; uncertainty, health insurance and the demand for care; moral hazard, adverse selection and cream skimming; professions and non-profit institutions; provider incentives and behaviour; production and pricing of pharmaceuticals; the health production function; measuring health and health gain; externality; publicness; efficiency; economic evaluation of health care technologies; determinants of population health; the health gradient; equity in health and health care. All else is either general economics, epidemiology or local description.

Private finance and private provision, or private finance and public provision, or public finance and private provision, or public finance and public provision. An embarrassment of riches!

Some things – health’s one – are good things both inherently and instrumentally.

There can be no right to health but there can be a right to health care.

You run the country’s public expenditure and you have £10m. Which is better: £10m extra spent on defence, or £10m extra spent on health care, or £10m extra spent on social care, or £10m extra spent on secondary education, or £10m extra spent on affordable housing, or £10m extra spent on law and order, or … £1m spent on each of ten such activities? (The correct answer is none of these.)

The World Health Organization, bless it, thinks that ‘health’ is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity. An immensely immodest claim.

We need a pragmatic measure of health. It should be a qualitative or even quantitative indicator of someone’s physical and emotional capability. It’s quintessentially multi-dimensional and should always be checked for acceptability in any given context.

The idea that health is utility means you can’t say, as I would prefer, that health, along with much else, can be measured like utility.

Utility’s neither welfare nor health.

Measured utility gives an order of what: willingness to pay, preference, taste, desirability, goodness, choice, satisfaction, contentment, welfare?

Maximising human satisfaction has less ethical appeal than maximising human flourishing.

Utility-maximising theory’s not a very good basis for predicting behaviour but a tolerably good one for prescribing it.

It’s what’s in your utility function, not merely that you have one, that defines you as selfish or unselfish.

Health and wealth are both capital.

The value of health rises when interest rates fall.

The NHS solves reasonably well the problem of how most fairly to pay for health care, but it still – and despite NICE – fails to address seriously the problem of what to include in the benefits package.

NICE routinely recommends interventions the NHS cannot afford.

Meeting needs with no charge at the point of use does not require public ownership. Most GP practices in the UK are not publicly owned, and never have been. What’s required is demand-side socialism, not supply-side socialism.

Supposing appropriate and enforceable contracts could be designed, why not privatise the supply side of the NHS and social care?

A hypothecated NHS and social care share of the tax take, voted on by the public at general elections. What’s not to like (setting aside self-serving objections by mandarins)?

Public ownership of the institutions of health care is not an end; it’s a means, to be tested for its cost-effectiveness.

The NHS Constitution: “We maximise our resources for the benefit of the whole community”. A slogan, bless them, wholly empty of implications for the size or allocation of the NHS budget!

Platitudes protect the powerful from probing.

Doctors, on the whole, are experts at diagnosing and treating illness; patients, on the whole, are experts at knowing what discomfort they can bear and what expense. Neither are especially expert at communicating what they know to the other.

All health insurance systems must find a solution to the problem that ill-health is, in aggregate, negatively related to income, and premiums are related positively to expected demand, so those facing the highest premiums are those least able to afford them.

The market’s a phenomenon to be understood, not idolised.

A public good is one whose benefits, if there are any, are necessarily shared, like public health measures and the King.

Health is part private and part public. The public part includes delight from the relief of another’s suffering, shared risk, reduced communicable disease, protection from fraud and ignorance, and legislated safety for all.

Ill-health can generate so many negative public externalities, physical and psychic, that health care can be treated as a quasi-public good.

Public health’s a great protector of private health.

Prevention is better than cure only when it is relatively cost-effective.

Some partly private goods are often better produced publicly, like trains and health care.

Public goods are not of their very nature to be publicly produced and paid for, but it usually saves a lot of bother if they are.

The critical difference between public and private ownership, in health care as elsewhere, is the freedom to buy or sell one’s part of it.

The most effective treatment is not automatically to be included in the publicly financed healthcare package; it must not be at the cost of alternatives that would deliver more health or more fairly distributed health for the same money.

It’s unhelpful sentimentality to suppose that treatments for dreadful diseases like cancers and multiple sclerosis should be provided by the NHS simply because they are dreadful. It’s even more dreadful to provide such treatments at the cost of not providing treatments for other conditions that bring much greater health benefits.

It’s not economics that denies anyone health care benefits. It’s the absence of a satisfactory means of delivering some benefits and a limited overall budget for health care.

Health economics enables one to think about the unthinkable but not to treat the untreatable.

A major disadvantage of charging for health care is that until there has been a diagnosis, what the patient needs is not known. A charge is a deterrent to finding out.

The NHS should provide cost-effective health care, and only cost-effective health care.

New interventions that reduce health inequalities are welcome – but only if they are cost-effective (a) at reducing the inequalities and (b) at increasing people’s health.

Cost-effective medicine is needed by patients as well as by sellers.

Cost-ineffective medicine is needed only by sellers.

Too high a NICE Cost-Effectiveness Threshold means the NHS will be both inefficient and underfunded.

The Secretary of State needs always to ask, “is it effective enough to be afforded?”

Cost-effectiveness is only a necessary, not a sufficient, condition for the NHS to offer a service.

The question for NICE: if the NHS spends on something new, what is displaced?

It’s easy to recommend some new way of spending NHS money if the losers are anonymous and invisible. Easy but not right.

Many cancer drugs, new and old, convey miserly benefits at the cost of using health care resources that would transform others’, including children’s, lives.

NICE was nice.

Health economists, like other experts, are in general no more expert than anyone else at making, as distinct from identifying, value judgements.

All health economists interested in technology evaluation should understand the difference between sensitivity and specificity in epidemiology.

All epidemiologists interested in technology evaluation should understand the difference between sunk and marginal cost in economics.

It’s scarcely surprising that cost-effectiveness analysis in health policy, conceived loosely and conducted carelessly, is not cost-effective.

The framework of cost-effectiveness analysis is like a battery-operated light, it brings illumination only with insertions – of context and value judgments.

The right answer in health care, as elsewhere, always depends on the context – as well as the arithmetic.

Economic efficiency is not intrinsically good. Whether it is good depends on what you’re being efficient at.

A cost-effective extermination camp is an abomination.

Cost is not merely a forgone alternative; it is the most valued of all feasible alternatives.

What’s feasible for a decision-maker depends on context: their position in a hierarchy, the rules that bind them, the information available to them, the discretion allowed them, and relevant law and custom.

Good policy guidance in health care requires the combining of heterogeneous evidence, of greater and lesser relevance, qualitative and quantitative, reliable and unreliable, with known and unknown biases, oral and written; together with thoughtful stakeholder meetings, good briefing, good chairing, and opportunities for discussion and debate. That’s all!

Judge a policy by whether it’s likely to work, not by its advocates’ hopes.

‘Impact’ doesn’t always mean ‘making a difference’; ‘no change!’ is sometimes the best kind of impact.

Consequentialists don’t say that consequences are the only things that matter.

A good debate’s informed by evidence (but rarely complete), by expert witnesses (but rarely free of bias) and should involve all important stakeholders (especially otherwise disempowered voices).

Group deliberation is participative meditation.

Changing the decision context changes consequences and thereby changes both opportunity costs and benefits.

Clear thinking and clear procedures are dangerous. They may expose vengeful incompetence.

Never imagine that your algorithm embraces all possible cases. It doesn’t, so always make contingency plans.

Scientific evidence in health care, as elsewhere, relates to the testing of hypotheses, uses recognised and replicable means of doing so and is analysed and interpreted using further recognised and replicable methods. Evidence lacking these features is worth little, even when it’s the only evidence available.

Costs are not facts, available like jetsam to any diligent beachcomber.

The faster the planned change the greater the cost.

The sooner the planned change the greater the cost.

The long run can be made the short run – if you throw enough resources at it.

Don’t take the ‘long run’ or ‘fixed factors’ literally. They’re just convenient conceits recognising the truth that some factors of production take more time and resources to change than others.

In 1892, the 213 miles of the Great Western Railway’s old broad-gauge track between Exeter and Penzance was changed to the standard narrow gauge in one weekend. 177 miles of it also had to be altered from the old longitudinal timbers to the familiar cross-sleepers. It took 4,200 platelayers to do it. So much for a ‘fixed factor’!

Cost in health economics is primarily (but not only) someone’s health forgone.

There’s much mileage in the idea that the cost of squeezing the last bit of benefit from anything (like abolishing malaria) approaches infinity.

Greed. Bias. Self-interest. Every bit of health care expenditure, public or private, total or incremental, is income for someone or other. E=I, ΔE=ΔI. Remember your national accounting identities most especially when you hear impassioned advocacy for increased spending.

When you hear ‘equality’ always ask “of what?”

Equality is not always equitable, and what’s equitable is not always equal.

Vertical fairness usually requires inequality.

To be born with a harelip’s a misfortune but not an unfairness. To have access to surgical closure of harelip only if you are white and middle class is unfair.

Scientists, especially environmentalists, economists and physicians, invariably exceed their authority on topics where they have none. So do non-scientists, like ethicists. Preachers all!

Why do failed philosophers become ethicists?

If you really want to ‘follow the science’ first understand it sufficiently well to interrogate the scientists.

Never be guided by scientists; learn instead how to interrogate them.

Alarm: academic authors are always absolutely awful at authoring abstracts.

The trouble with written English is that they can’t see the English twinkle in your English eye.

You’ll mean what you say only if you’re able to say what you mean.

A good idea badly expressed is a bad idea.

You may not have much to say but at least give joy to others by saying it well.

Show respect for aged health economists: they’ve probably forgotten more health economics than you’ve ever learned!