Brendan Collins’s journal round-up for 3rd December 2018

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

A framework for conducting economic evaluations alongside natural experiments. Social Science & Medicine Published 27th November 2018

I feel like Social Science & Medicine is publishing some excellent health economics papers lately and this is another example. Natural experiment methods, like instrumental variables, difference in difference, and propensity matching, are increasingly used to evaluate public health policy interventions. This paper provides a review and a framework for how to incorporate economic evaluation alongside this. And even better, it has a checklist! It goes into some detail in describing each item in the checklist which I think will be really useful. A couple of the items seemed a bit peculiar to me, like talking about “Potential behavioural responses (e.g. ‘nudge effects’)” – I would prefer a more general term like causal mechanism. And it has multi-criteria decision analysis (MCDA) as a potential method. I love MCDA but I think that using MCDA would surely require a whole new set of items on the checklist, for instance, to record how MCDA weights have been decided. (For me, saying that CEA is insufficient so we should use MCDA instead is like saying I find it hard to put IKEA furniture together so I will make my own furniture from scratch.) My hope with checklists is that they actually improve practice, rather than just being used in a post hoc way to include a few caveats and excuses in papers.

Autonomy, accountability, and ambiguity in arm’s-length meta-governance: the case of NHS England. Public Management Review Published 18th November 2018

It has been said that NICE in England serves a purpose of insulating politicians from the fallout of difficult investment decisions, for example recommending that people with mild Alzheimers disease do not get certain drugs. When the coalition government gained power in the UK in 2010, there was initially talk that NICE’s role of approving drugs may be reduced. But the government may have realised that NICE serve a useful role of being a focus of public and media anger when new drugs are rejected on cost-effectiveness grounds. And so it may be with NHS England (NHSE), which according to this paper, as an arms-length body (ALB), has powers that exceed what was initially planned.

This paper uses meta-governance theory, examining different types of control mechanisms and the relationship between the ALB and the sponsor (Department for Health and Social Care), and how they impact on autonomy and accountability. It suggests that NHSE is operating at a macro, policy-making level, rather than an operational, implementation level. Policy changes from NHSE are presented by ministers as coming ‘from’ the NHS but, in reality, the NHS is much bigger than NHSE. NHSE was created to take political interference out of decision-making and let civil servants get on with things. But before reading this paper, it had not occurred to me how much power NHSE had accrued, and how this may create difficulties in terms of accountability for reasonableness. For instance, NHSE have a very complicated structure and do not publish all of their meeting minutes so it is difficult to understand how investment decisions are made. It may be that the changes that have happened in the NHS since 2012 were intended to involve healthcare professionals more in local investment decisions. But actually, a lot of power in terms of shaping the balance of hierarchies, markets and networks has ended up in NHSE, sitting in a hinterland between politicians in Whitehall and local NHS organisations. With a new NHS Plan reportedly delayed because of Brexit chaos, it will be interesting to see what this plan says about accountability.

How health policy shapes healthcare sector productivity? Evidence from Italy and UK. Health Policy [PubMed] Published 2nd November 2018

This paper starts with an interesting premise: the English and Italian state healthcare systems (the NHS and the SSN) are quite similar (which I didn’t know before). But the two systems have had different priorities in the time period from 2004-2011. England focused on increasing activity, reducing waiting times and quality improvements while Italy focused on reducing hospital beds as well as reducing variation and unnecessary treatments. This paper finds that productivity increased more quickly in the NHS than the SSN from 2004-2011. This paper is ambitious in its scope and the data the authors have used. The model uses input-specific price deflators, so it includes the fact that healthcare inputs increase in price faster than other industries but treats this as exogenous to the production function. This price inflation may be because around 75% of costs are staff costs, and wage inflation in other industries produces wage inflation in the NHS. It may be interesting in future to analyse to what extent the rate of inflation for healthcare is inevitable and if it is linked in some way to the inputs and outputs. We often hear that productivity in the NHS has not increased as much as other industries, so it is perhaps reassuring to read a paper that says the NHS has performed better than a similar health system elsewhere.

Credits

Conference round-up: Medicine, Markets and Morals Network Meeting Three

Last October saw the first meeting of the Medicine, Markets and Morals Network. Today and yesterday I attended their third and final (for now) meeting in London. The network brings together researchers from across the social sciences and humanities to discuss issues relating to resource allocation in health care. A book is planned and the website will be maintained, so hopefully the Network has a future and will produce something more permanent. For now, here are some of the overarching themes that I saw being discussed at the conference.

To deliberate or not to deliberate?

I don’t know what it is about philosophers that enables them to talk so well without slides. The conference started with a prime example in the shape of Jonathan Wolff discussing alternative approaches to valuing health care. Should we consider preferences, experienced utility or capabilities? And whose? Jo suggested that there is no single best approach and argued in favour of a discursive, deliberative approach.

This became a recurring subject for the event, to which we returned on the final day with Ruben Andreas Sakowsky arguing that deliberative evaluation is a better way of eliciting individual preferences. To this end, he suggested that we ‘upgrade’ the way we do discrete choice experiments. Leah Rand argued that we need to upgrade the notion of ‘accountability for reasonableness’, which is at the heart of decision-making processes in health care. Leah argued that there is a need to ensure legitimacy in the process of decision-making and a requirement for fair consideration of reasons.

But deliberative processes present challenges. Do people know enough to make informed decisions about the allocation of health care resources? If they don’t then there is still an argument to be made that in a democracy it is the views of these people that should be acted upon. But can deliberation still be meaningful if the people involved have no understanding of the context or implications of their decisions?

Information – particularly who has it and which bits of it matter – was the major theme of the conference for me. I think a lot of what we discussed related to the incompatibility of evidence-based policy and democracy. I’ll come back to that later, once I’ve discussed some of the other speakers’ talks.

Systems, structures and marketisation

Another major subject was the Health and Social Care Act 2012 (HSCA). Richard Taunt discussed the HSCA, noting the tendency for people to view the apparent fiasco as undemocratic. Richard argued that this is not the case, but rather issues like this have “no salience in electoral politics”. Even if people say that NHS policy will determine which way they vote, in reality votes don’t correspond to what people say is important. One option is to build sustainable development into democracy, such as has been tried with the Well-being of Future Generations (Wales) Act or the Finnish ‘Committee for the Future’. But, Richard argued, we already have the Health Select Committee and plenty of think tanks; ‘upgrading democracy’ should not be about structures. Rather, we should focus on encouraging the right kinds of behaviours, such as humility and continual learning.

Later in the day, Allyson Pollock presented a quite different story about the Health and Social Care Act; as providing the mechanisms for the deconstruction of the NHS. Allyson explained that the Act does away with the duty to provide universal health care according to need, and that the closure of hospitals is the evidence of this possibility being realised. The risk presented was that we might end up with a US-style system of health care funding and provision.

Therese Feiler presented a theological basis for the use of economics-type thinking in health care, which took us all out of our comfort zone; a great thing! Therese suggested that the use of diagnosis-related groups (DRGs) is a part of the process of the commodification of health care.

Mary Guy discussed the legal situation in the UK and The Netherlands regarding the application of competition law to health care, which is key to the potential for marketisation of the NHS. The take home message is that whether or not the NHS could be subject to competition law (in its current organisation) is still to be decided in the courts.

Rudolf Klein gave a notably lo-fi talk on the need to ration expectations rather than treatments or procedures. He argued that the NHS agenda is determined by the state of the economy. While the NHS Mandate (which we were all encouraged to read) lists many goals, the top item on the list of NHS ‘must-do’s relates to financial stability. The question is, what are we willing to sacrifice from the long list of NHS goals? (There was support in the room for allowing longer A&E waiting times.) And what about the cost of transparency and statistics in order to maintain ‘anticipative accountability’, which is held to be very important? Can we sacrifice some of these costly processes which in turn help create more goals for the NHS mandate?

Evidence, narratives and democracy

Chris Newdick argued that bioethics hasn’t done us much good, in that the focus on autonomy has bolstered neoliberalism. He discussed the notion of public health ethics and asked why community is not the starting point for the ethical debate rather than the individual. In this sense, has the neoliberal agenda been more successful in the debate about health care, as well as more broadly?

I think this brings us back to the issue of information. The idea that autonomy and/or the free market is paramount is an a priori notion. The invisible hand is a nice story, and people are compelled by it. Evidence, on the other hand (the visible hand), is not compelling. One can always find evidence to support a claim and as such the non-expert may be inclined to distrust all evidence. A compelling story is more difficult to disregard.

In his closing remarks, Cam Donaldson mentioned Robert Evans’s notion of zombie policies. These are not usually evidence-based zombies but about stories. Cam presented Alan Williams’s old argument about the distinctiveness of health care as akin to a duck-billed platypus. This provides a nice analogy, but it still depends on evidence. This is why we see the ‘health care is just another good’ argument coming back time and time again; recently in the broccoli debate in the US.

The problem is that the basis for publicly provided health care requires a lot of thought and a lot of foundational understanding of how things work in a particular economic, political, legal, historical and ethical context. For example, to know that health care is not broccoli you need to understand moral hazard (etc), and that this has been observed. There is evidence. However, in order to support neoliberalism and a free market in health care you don’t need any of that. All you need is basic intuition and a compelling heuristic: leave people, institutions and corporations to do as they please and the invisible hand will sort it all out.

This at least partly explains why academics tend to think differently about resource allocation in health care. Rachel Baker and Helen Mason presented their work on eliciting public views about the allocation of resources at the end of life. Using Q methodology (for which we were given a brief tutorial) they have identified three different viewpoints that people tend to adopt. The first group support the notion of value for money, with no special cases; QALY-maximisers would fit into this group. The second believe that life is precious, and they are not likely to accept any restriction of health care due to costs. The third is a more nuanced group that value wider benefits while also acknowledging the importance of opportunity cost.

On the first day we attendees were presented with 18 statements, with 7-point likert scales to elicit our agreement. The same questionnaire was used in a large online survey of a representative sample of the UK. This survey is designed to elicit the prevalence of the different viewpoints. Viewpoint 2 was by far the most common in the general population. Meanwhile, in the room, viewpoint 3 was the leader. As for me, the stats showed that I was the strongest supporter of viewpoint 3. This discrepancy between the public and a group of academics may not come as a surprise, but it is noteworthy. Viewpoint 3 is the most nuanced position. It acknowledges the messyness of health care resource allocation decisions. The findings of the survey suggest to me that the public do not recognise this messyness, or at least employ a simpler decision process that ignores some of the messyness. They may be right to do so, but I suspect not. As academics we know more about what we do not know; we have more known unknowns. The general public on the other hand don’t – and can’t be expected to – understand all of the challenges of resource allocation in health.

One of the very last points to be raised in the concluding discussion was whether homeopathy should be funded on the NHS. Most of us agreed it shouldn’t, but Ruben bravely stuck his neck out and suggested that if people want it then who are we to deny it? I think there’s an analogy to be drawn here between homeopathy and free market health care. We know homeopathy isn’t good for people. We know market forces in health care (broadly speaking) aren’t good for people. But both of these assertions are empirical; dependent on understanding a long history of evidence and fundamental notions of how we determine what is good for people. The public don’t have this understanding. The ‘invisible hand’ and ‘like cures like’ make for far more compelling and easily attainable interpretations of reality. So people will vote for them. But that is not a good thing.