Let’s talk about the NHS 1: we need a common language. #Health

The 3 Es: employment, ‘ealth and education

Photo by Priscilla Du Preez 🇨🇦 on Unsplash

Health is huge but we can’t describe success and failure in terms that everyone understands, so we jump straight to value-laden conclusions: doctors and nurses are heroes, or they simply don’t care; the government loves the NHS or wants to starve it into submission.

Is there hope for a common language?  Here’s my take after half a lifetime of investigation:

• We need universal terms for what happens to patients…

• …and for what they experience during their care…

• …and for what it costs and what we can afford.

Let’s start with health itself – what is it and can we measure it? We’re not going to write an entire dictionary, just make a start.

I didn’t get into healthcare until my late thirties. Having grown up wearing artificial legs and gotten by with a couple of thumbs and several fingers fewer than everyone else, I kept business and home life separated.

I’d run a small photonics R&D division and knew how to deliver vast amounts of information but wondered how it would sell. In the event, it has taken Telecoms 40 years (and counting) to get fibre from the lab to every home.

Meanwhile, I visited CERN to see how they extracted colossal amounts of data every few nanoseconds; looked down the hole in Texas where the US was planning its supercollider; and explored other markets. Then I discovered health with its startling mismatch between information needs and provision!

Not long after, I parachuted into a chair at Brunel and eventually led a multi-million pound programme in health technology across several universities. From my industrial background, I felt there was an obvious approach to value through business models, but was suddenly surrounded by academic doctors, nurses, health economists, engineers and sociologists. I liked all their ideas, even though some clashed with others. And I discovered QALYs.

Why the QALY is a terrible idea but not quite as terrible as all the others

Clocking on at the NHS factory: Lessons from industry (HSJ 2015) introduces QALYs as an economic construct where you have a utility of 1 in perfect health and 0 when you are dead. It says it helps to think of every health facility as a factory that pumps health into the community.

I know pantos are a contested area, but the season is almost upon us so let’s think theatrically: an inert form lies in a wood.  The NHS wanders up and kneels over the stricken figure but instead of slicing it open to let out the Big Bad Wolf or shoving a golden apple down its throat (or however these plots go), the NHS reaches into a case and pours a single QALY into the victim.

The inert form is suddenly full of beans (another panto, perhaps) and enjoys a year of perfect health. Once that QALY has expired our hero expires, too, just in time for next year’s panto.  Except, it’s not quite a year because we apply what is laughingly called (Oh no it isn’t!) a discount rate.  It’s small – a few percent – but, counterintuitively, the QALY runs out a week or two after the NHS appears centre stage once more in a winter crisis, so our thespian corpse misses the start of the season.

This highly abstracted view is the best I know for measuring healthcare. 

On very few occasions an inert form is helicoptered into a trauma centre and saunters away after much intervention, to live happily ever after. Mostly, our health deficits are more modest: perhaps a dodgy hip has limited our mobility with, say, a utility around 0.75. A new hip may boost it to 0.95 for 10 years, so that we receive 0.2 x 10 x the discount factor, or almost 2 QALYs.

I see 4 problems with the QALY:

1. It’s an abstraction. There is no QALY-meter for patients entering and leaving healthcare encounters. Worse still, some QALY estimates are much less satisfactory than others.

2. It’s an economic construct that must be implemented using clinical and business processes. For me, significant benefit is lost in translation.

3. It may represent a universal quantum of need, but different needs cost different amounts to address. For instance, dementia can cost us all we have without relenting while new knees cost less than most cancer treatments.

4. There are issues of belief and statistical approach. I suspect I’m more deontologist than utilitarian; I like Bayes but am happy to pick and choose. I see the QALY as a practical proposition that clarifies decisions.

Over the past quarter of a century, NICE has fought for the QALY in decision-making, with a threshold of up to £20,000 or £30,000 per QALY in deciding which drugs and treatments the NHS should offer. Furthermore, QALYs are embedded in law and policy. The Green Book, for instance, offers a benefit value of £70,000 per QALY (section 9.3).

What might happen if we all talked QALY a little better?

Here are 3 tasters.

The health factory

What if we could measure how much health every facility in the UK was dispensing to us? Here’s a short article that shows how to balance costs and QALYs in everyday decisions, such as closing or commissioning wards, or designing new community services.  So often, the hidden health costs or benefits are only discovered in the wreckage afterwards.

If only we knew how many QALYs a year every GP surgery, clinic, hospital, walk-in centre or one-stop shop was providing for its community!  It would revolutionise how we talk about the NHS.

Other services

A friend has just joined the top team of a company wholly owned by local government that targets a specific population and must make substantial savings. When he asked the Finance Director if they needed better value or to make cuts, he got the response: good question!

In-year savings usually force cuts, but strong strategic cases can leverage QALYs. What is the utility of those for whom the company intervenes and those for whom it doesn’t?  Start with proxies – A&E attendances, absenteeism and usage of other services, say – and expect the data to improve as you learn what to look for.  Once you know roughly how many QALYs are consumed by clients compared to the wider population, make the case or close your company!

Everyday thinking

Years ago, my wife had chest pains one Friday afternoon and didn’t get the all-clear until Tuesday.

As I sat with her in A&E, I started to imagine two dials above everyone’s head: one clicking up the cost of being there; the other showing utility.  On the ward, my wife’s utility declined steadily throughout the weekend, but not because of any chest pain. For example, the ward was incredibly noisy and when she finally fell asleep, they woke her to take blood because the IT system had lost her results. If only anyone had been watching those dials…

As waiting lengthens, costs click up (however slowly) and utility usually clicks down. What if we could all see everyone’s utility and costs in real-time? Once everyone could see those dials, we would have taken our first steps toward a common language around the NHS and could talk much more constructively about what is working and what isn’t.

Professor Young: researching for 40+ years; in healthcare for 25; and using NHS limbs for 50+.

The series

Let’s talk about the NHS 1: we need a common language (12 September 2024)

Let’s talk about the NHS 2: when was the golden age? (19 September 2024)

Let’s talk about the NHS 3: why have hospitals so successfully harvested ever more of the budget? (26 September 2024)

Let’s talk about the NHS 4: how many honest conversations can we have? (3 October 2024)

Let’s talk about the NHS 5: why health probably won’t create wealth. (10 October 2024)

Let’s talk about the NHS 6: how close is an integrated NHS? (17 October 2024)