# Meeting round-up: The Role of the University of York in the Development of Health Economics

By Eleanor MacKillop and Sally Sheard

On 27th October 2017, some key British health economists were reunited to discuss the origins and development of their discipline. The event, held at the Centre for Health Economics at the University of York, formed part of the ‘Governance of Health’ project, led by Professor Sally Sheard at the University of Liverpool. Health economics (HE) now dominates British and foreign health policy and decision-making, as illustrated by the resource allocation formula, the formulation of the quality-adjusted life year (QALY), or the introduction of quasi-markets in the NHS, and NICE.

Witness seminars provide an opportunity for collective and public oral history. The event chronicled a history that has rarely been examined, and then only by economists. Using open questions, the witnesses explored the origins of British HE, relationships with the Department of Health (DH) and how it infiltrated other areas such as the NHS – the word ‘infiltrating’ was often repeated by witnesses.

# Origins of health economics in the UK

For Tony Culyer, his personal experience of health economics began in 1964 when working with Mike Cooper at Exeter University. Mike Cooper had previously worked with Dennis Lees at Keele University and the Institute of Economic Affairs (IEA). For other witnesses, their first brush with economics as applied to health – the term ‘health economics’ was not used until much later – came through the MSc and PhD programmes at York. The creation of the University of York in 1963 allowed new disciplines such as economics to develop in a less rigid environment as compared to Oxbridge. A similar pattern emerged at the University of Aberdeen and Brunel University.

Dr Alan Haycox and Professor Karen Bloor sharing their stories

Why York rather than other more established centres? Several witnesses explained that there was a ‘snobbery’ and that HE was seen as ‘a waste of time’ and ‘not proper economics’. Another crucial event was the ‘coup’ of York of recruiting two leading economists – Alan Peacock and Jack Wiseman – to start an economics department which was first inaugurated as the Institute of Social and Economics Research (ISER) in 1964. However, as noted by some witnesses, the political inclinations of these two economists, who were close to the free-market-leaning IEA, may have hindered York’s early relationship with Government. The hiring of Alan Williams in 1968 – seen by many as, ‘inspirational and fascinating’ and equipped with ‘a relentless logic’ – was also a defining event in the development of economics at York. It is important to note that the first health economics centre was established at Aberdeen – the Health Economics Research Unit (HERU) in 1977 – and that the Centre for Health Economics (CHE) at York wasn’t inaugurated until 1983. More generally, the financial and economic context of the 1970s, with the oil shocks, devaluation of the pound and beginning of years of budget restrictions, was an obvious factor in making HE a helpful discipline for successive governments.

# Health economics in government

David Pole, first Chief Economist for health in the Department of Health and Social Security (DHSS), was a key individual, entering the Department’s Economic Advisers’ Office (EAO) as a senior economic adviser in 1970, shortly followed by Jeremy Hurst. They tried to convince some hostile medical professionals and administrators of the merits of their approach. Ron Akehurst explained how the attempt by administrators to hide from the then Minister of State for Health – David Owen – a report on the geographical inequalities in the allocation of resources in the mid-1970s led the latter to liaise directly with David Pole and the EAO, and the emergence of the resource allocation formula. A former economic adviser in DH, Andrew Burchell, reminisced how David Pole and his successor Clive Smee were successful in identifying academic research that could be grafted onto policy – such as QALYs from the mid-1970s – and seizing opportunities as they arose.

Photograph of schema fusing painfulness and restriction of activity into a single dimension (TNA, MH166/927, Economics of Medical Care, ‘Health Indicators’ report submitted by Culyer, A., Lavers, R. and Williams, A. to the DHSS, p. 29, 1971)

The inauguration of CHE in 1983 and its funding as a DHSS research unit forged a closer relationship between York and government. Public Health England’s Chief Economist, Brian Ferguson, noted how Alan Maynard would often speak of ‘infiltrating the field and government’. More generally, York was successful at delivering research and reports that DH could use, such as Peter Smith’s work on the cost of teaching hospitals in the early 1970s and Ken Wright’s work on ambulances and social care.

# Health economics in other contexts and key achievements

From the 1980s, witnesses Anne Ludbrook, Alan Haycox and Ron Akehurst worked as economists in Regional Health Authorities in England and Scotland. They talked about the difficulty of getting the HE message across to doctors and managers, and making decisions more transparent.

Ron Akehurst spoke about how he was commissioned by DH to run HE training courses for doctors. A number of other contributions were mentioned, but most witnesses agreed that NICE was the ‘single most important impact of health economics on policy’.

# What we have learnt: three key messages from the Witness Seminar

1. Opportunities created: Witnesses highlighted the importance of chance and the unpredictability of events which led to health economics playing an important role. The resource allocation formula or research on teaching hospitals’ costs provide examples of chance and the ways in which economists were prepared for playing a greater role in policy development.
2. Role of charismatic individuals: David Pole, Clive Smee, Alan Williams, Tony Culyer and Alan Maynard were all seen as individuals – maybe even ‘policy entrepreneurs’ – who were capable of presenting convincing arguments to different audiences, be they politicians, administrators or the NHS, and able to negotiate between policy communities.
3. An ongoing project: Although the panel noted the importance of Health Technology Assessment (HTA) today, Karen Bloor and others reminded us that HE isn’t a battle ‘won’ but instead an ongoing phenomenon developing into a multiplicity of branches.

Thanks to Michael Lambert and Phil Begley for their help editing this post

# Hawking is right, Jeremy Hunt does egregiously cherry pick the evidence

I’m beginning to think Jeremy Hunt doesn’t actually care what the evidence says on the weekend effect. Last week, renowned physicist Stephen Hawking criticized Hunt for ‘cherry picking’ evidence with regard to the ‘weekend effect’: that patients admitted at the weekend are observed to be more likely than their counterparts admitted on a weekday to die. Hunt responded by doubling down on his claims:

Some people have questioned Hawking’s credentials to speak on the topic beyond being a user of the NHS. But it has taken a respected public figure to speak out to elicit a response from the Secretary of State for Health, and that should be welcomed. It remains the case though that a multitude of experts do continue to be ignored. Even the oft-quoted Freemantle paper is partially ignored where it notes of the ‘excess’ weekend deaths, “to assume that [these deaths] are avoidable would be rash and misleading.”

We produced a simple tool to demonstrate how weekend effect studies might estimate an increased risk of mortality associated with weekend admissions even in the case of no difference in care quality. However, the causal model underlying these arguments is not always obvious. So here it is:

A simple model of the effect of the weekend on patient health outcomes. The dashed line represents unobserved effects

So what do we know about the weekend effect?

1. The weekend effect exists. A multitude of studies have observed that patients admitted at the weekend are more likely to die than those admitted on a weekday. This amounts to having shown that $E(Y|W,S) \neq E(Y|W',S)$. As our causal model demonstrates, being admitted is correlated with health and, importantly, the day of the week. So, this is not the same as saying that risk of adverse clinical outcomes differs by day of the week if you take into account propensity for admission, we can’t say $E(Y|W) \neq E(Y|W')$. Nor does this evidence imply care quality differs at the weekend, $E(Q|W) \neq E(Q|W')$. In fact, the evidence only implies differences in care quality if the propensity to be admitted is independent of (unobserved) health status, i.e. $Pr(S|U,X) = Pr(S|X)$ (or if health outcomes are uncorrelated with health status, which is definitely not the case!).
2. Admissions are different at the weekend. Fewer patients are admitted at the weekend and those that are admitted are on average more severely unwell. Evidence suggests that the better patient severity is controlled for, the smaller the estimated weekend effect. Weekend effect estimates also diminish in models that account for the selection mechanism.
3. There is some evidence that care quality may be worse at the weekend (at least in the United States). So $E(Q|W) \neq E(Q|W')$. Although this has not been established in the UK (we’re currently investigating it!)
4. Staffing levels, particularly specialist to patient ratios, are different at the weekend, $E(X|W) \neq E(X|W')$.
5. There is little evidence to suggest how staffing levels and care quality are related. While the relationship seems evident prima facie, its extent is not well understood, for example, we might expect a diminishing return to increased staffing levels.
6. There is a reasonable amount of evidence on the impact of care quality (preventable errors and adverse events) on patient health outcomes.

But what are we actually interested in from a policy perspective? Do we actually care that it is the weekend per se? I would say no, we care that there is potentially a lapse in care quality. So, it’s a two part question: (i) how does care quality (and hence avoidable patient harm) differ at the weekend $E(Q|W) - E(Q|W') = ?$; and (ii) what effect does this have on patient outcomes $E(Y|Q)=?$. The first question answers to what extent policy may affect change and the second gives us a way of valuing that change and yet the vast majority of studies in the area address neither. Despite there being a number of publicly funded research projects looking at these questions right now, it’s the studies that are not useful for policy that keep being quoted by those with the power to make change.

Hawking is right, Jeremy Hunt has egregiously cherry picked and misrepresented the evidence, as has been pointed out again and again and again and again and … One begins to wonder if there isn’t some motive other than ensuring long run efficiency and equity in the health service.

Credits

# Weekend effect redux

The ‘weekend effect’ has continued to make headlines since we last posted about it. Last week an open letter to beleaguered Secretary of State for Health Jeremy Hunt was published in The Guardian by a number of prominent scientists and clinicians calling for an inquiry into the seven day NHS policy and the evidence behind it. And on Monday a further article was published in The Guardian that reported on the findings of a new study in the British Journal of Psychiatry in which it was reported that there was no increase in the risk of mortality for mental health patients in England. Rashmi Patel, the lead author of the study, was quoted as saying that in relation to increased mortality associated with weekend admission their study had shown ‘no significant difference’ and,

Our study does not support the need to have more doctors on duty at the weekends in psychiatric hospitals. In fact, if this means having to reduce the provision of doctors during the week to provide more doctors at the weekend, this could harm patient care.

But, this is not necessarily true, and it goes to show the difficulties with interpreting and translating evidence into effective policy.

I think part of the problem lies with the mindset of there either is or there isn’t a weekend effect. Perhaps this dichotomy has been ingrained into our psyches by hypothesis testing and p-values. But, it’s a bad way to think about it; care does differ between the weekend and weekdays therefore it is quite plausible that care quality differs as well. I don’t think many people believe in what we’ll call strong weekendism, which might be described as there being no patient who would experience a different overall health outcome if they are admitted at the weekend or on a weekday. However, some people may take the weak weekendism position, which might state that no patient who was admitted on a weekend and who died would have survived had they been admitted on a weekday. However, only the strong weekendism position necessarily supports a conclusion that the 7-day NHS policy is unwarranted. Thus, the aforementioned open letter to Jeremy Hunt seems to take too strong a line. However I think both the strong and weak positions are too strong, the most plausible position in my view is that care quality is worse at the weekend. It’s just a question of how much.

Once the question is reframed about the magnitude of the effect rather than its existence, we can start debating whether a policy to remedy care quality differences is worth it. Contrary to Rashmi Patel’s claims above, their study may or may not support increasing clinical staff provision at the weekend. The evidence we have previously covered on this blog provides preliminary evidence that it is highly unlikely that the 7-day NHS policy will be cost-effective by any standard measure. This should be the focus of the debate, not whether a weekend effect exists or not.

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