Okay. Good evening, everyone. Thank you for being here.
I see some familiar faces from the department and a few faces from not as many as I'd hoped from my module,
but that hey, it's a, it's been a long day and some faces I don't recognise.
So thank you all for being here today for what's what's a first actually for for us is a is a I've
never hosted a debate and I've tried to stick to the Oxford rules or the Oxford Union rules,
which I should describe to you. Believe me, there are rules you'll be probably unsurprised to know.
But we've got a talk with a debate between a say between I don't know if it's between verses.
I feel competitive, I thought, using these sorts of phrases. So I should be mindful of not doing that.
But we're talking about value based health care and health economics repackaged, or is it a repackaging of health economics?
And actually, the the the proposal has her own it's her own fault and herself to blame us for being here tonight,
because she wrote a very interesting and provocative blog, which you should all go check out Lucy Abel's blog.
And it started to spark this debate tonight. So Lisa will be proposing and some grey will be opposing for tonight.
I shall just relay the rules to I'm not taking Twitter.
I'm just on my phone relaying the rules I sent to the team for what we're doing tonight.
So the official rules are that you will have 10 minutes each to debate the first minute and the last minute of the talk are protected time apparently.
So you may not interrupt or suggest or offer any inter interjections during those time periods,
but any other time point you may I shall keep time and we have a bell.
I'm I am to ring the bell every minute to inform you that a minutes has lost every minute.
Every minute. Apparently, according if I didn't have a bell, I was going to use Kakar type noises, but luckily we found a bell.
So you don't have to hear me shouting out caller every every minute you may offer points of information
is what they're collectively you're technically called as a whilst your colleague is holding the floor,
you can offer a points of information and usually no more than about 15 seconds
please for these points of information and the speaker holding the floor,
you may accept or reject them at your own, at your own will.
At the end, I will let both speakers talk and then at the end we will have a vote.
And then I'll open up to questions and we can discuss as to why we voted the way we voted.
So who do we favour for or against?
Is that everything clear? Any questions from the speakers? Nope.
All right. Without further ado, then I shall hand the floor over to Lucy Abel.
That wasn't good. Tell me when you're going to start ringing and picking me up.
Can I have your hand back? Excellent. Let me know when to go.
Time starts. Yeah.
Okay. So the proposal before us is, is value based health care anything more than recreating health economics?
And I'm going to argue that it first isn't.
And second, it's attempts to do so will, in fact, result in worse patient outcomes in our health system.
And I think the the way to sort of keep this up is with a little bit of history of whereby this health care's come from.
And the short answer to that is America. In the US over the last 20 years.
Health care costs have exploded. And this has led to a renewed interest in health economics sort of approaches to try
to contain some of those costs and ensure that the health system is being valuable,
that the US doesn't really like cost effectiveness.
There's an ethos of seeing it as rationing and therefore it's been rebranded and it's been called value based healthcare.
And in America you can buy value based insurance and it uses like base pricing and you can be treated in a value based hospital network.
And these constructs are all developed by health economists.
There aren't value based health care advocates in the same way that there are in the UK.
There's a few, but most of the people working on value based initiatives a health economist in the UK is a little bit different
and Neil has kindly written a number of articles explaining how value based health care works and how to find.
And there are three key definitions that crop up allocated value, technical value and personal value.
Excellent. I'm going to explain what these are.
Explain why health economics already covers this ground and why the approach that value based healthcare is taking and redefining these is,
in fact, worse. So let's start with elective value, which is all about allocating resources in a way that maximises equity and value.
You're going to notice a slightly circular argument there that we can we can value to value value.
And I've never seen a particularly good definition of value in value based health care.
So I'm delighted that hopefully we agree, will give us a crystal clear, explicit definition of value.
In health economics, we use the quality adjusted life year, they call it.
It combines length of life data with quality of life data. It's based on public preferences for different health states.
It's very well defined. We at least know what we're dealing with now in cost effectiveness analysis and in health economics.
What health economics already does.
You take your colleagues, you take your costs, you divide your colleagues by your costs, and you get a cost effectiveness ratio.
This equation is also used in value based health care. It's been rebranded as the value equation.
It is also quality over cost.
Now, value based health care talked a bit more explicitly about using equity in a way that cost effectiveness sometimes doesn't.
But you can use equity in health strategies analysis. You can bring equity into it.
You can say, we're going to invest more in people with poor health.
The key difference is that because we use the quality, because we have this cost effectiveness ratio, we know what we're giving up.
In choosing to do that doesn't mean it's a bad thing. It just means that we know that if you're going to divert some resources over here,
you understand who is paying for that with their own health outcomes. You might still want to do it.
It might still be really important because those gains for people with poor health are all really important.
But you're paying for them with health outcomes and we understand that and we can justify it and it's transparent.
So technical value. I don't know what technical value is.
I have not seen a good definition for it. I'm really hoping we're going to get one today.
It seems to be related to things like patient safety, health care efficiency, reducing waste, that sort of thing.
The key question really is, are we maximising health with trying to achieve technical value if we're not maximising health?
Why not? What what is this trying to achieve?
Because any sort of patient safety initiative through a health economic lens will fundamentally come down to improving health outcomes for patients.
The third definition is personal value. Personal value has a really lovely definition, which is that I've seen,
which is using clinical expertise in combination with patient values based on the best available evidence.
We're on an evidence based medicine course today. That is a textbook definition from Dave Sacca of evidence based medicine.
So we have allocated value, in other words, cost effectiveness analysis.
We have technical value, possibly also cost effectiveness analysis.
If not, I'm not sure what it's for. And finally, we have personal value, which is evidence based medicine.
Now in the UK, though,
your best health care does seem to be trying to achieve something a little bit different from what health economics is trying to achieve.
I've seen news of the startle and these value based healthcare interventions and I think
they're worse than cost effectiveness methods and I think they're worse than health economics.
The reason I think this is because I think that the goal is to make health economics more pragmatic.
I think it's about trying to make it more amenable to decision makers.
Bypass some of the most tricky decisions by only working within a particular budget,
for example, and generally make the whole thing a little bit tidier.
Health economics is really hard. Choosing between initiatives is really hard, and I think value based healthcare is trying to make it easier.
I think that's bad. I think it reduces the ambition of the health care system.
The reason I think this is to if you're working within the construction of the health system,
if you're working within the way the budget is already allocated,
you're not thinking in broad terms, then I think you risk being less ambitious in the kind of health care you want to provide.
So I'll take an example.
There's a paradox in health economics that we're trying to reconcile at the moment, which is called cost effective but unaffordable.
And it's what happens when cost effectiveness runs into budget impact analysis.
So the idea of what is this going to do to our budgets? And the recent example is the cure to treatments for hepatitis C.
These are highly cost effective. But they're not provided as widely as they should be because they eat up budgets.
So many people have this condition and these aren't cheap treatments, but because they work really well, they're still cost effective.
Now, if you take more of a budget impact view and more of a value based view and you try and make this fit within the current bureaucratic,
bureaucratic constraints of the NHS, what you end up doing is undermining that cost effectiveness, reducing the ambition,
not trying to find ways of reorganising the health care system to provide these treatments.
And I think that would, in the long term, result in worse outcomes for patients.
So to sum up, qualities are measurable and understood.
And they make sense. They're not easy, but they're transparent.
We understand what they're trying to do. Value based health care has yet to define what value is.
We don't know how it's going to respond to these questions of budget savings if it's
going to be suitably ambitious in the way that cost effectiveness analysis is.
So until we get a good definition of value, I don't think there's any good reason to move away from the health economics paradigm.
And I think the value based health care risks undermining it in a way that will ultimately hurt patient outcomes.
Thank you. Because of the technical transfer of microphones and what I see you've actually stuck to the official 7 minutes.
Oh that the Oxford only that gives you so you I gave them extra I give it three extra if I thought we're going a little bit beyond
the Oxford Union debate but we've we've managed to hit seven so when news ready to rock and roll I shall hand the floor to you.
Do you feel you can you didn't take to do it and feel free to do that if you would like to see them over to you team.
But one of the joys of working auction is the obsession with language.
I met someone I know who worked for Europe in the dictionary, and I would say here I said, the way we do this for a year and each he said, Well done.
But he's moved on to Ebony or something else. Now I don't know what else.
Do you spend the money working on each? So let me start with the definition and value based.
Healthcare was invented in Oxford two years before America.
I've been awfully good at talking about what they do, the Americans and very often health care.
But they're off. Good job in order to do so. We wrote the first value based healthcare report in 2006 for NHS England at the Department of Health,
and we created three aspects about the first discussion.
And. How is how is the outcome for this passion related to the problem that has bothered you the most?
Subjective. You can measure the autonomy score, but we have to think what is bothering people.
For example, I say I met a friend and they said, Would you come and meet my wife and myself?
And they say, I need another business. And I said, okay.
So I went to see him and I said, What's the problem?
And he said, Oh, Patricia said. And his wife complains of walking peacefully.
That's what changed your life. And she liked that situation very much and but they hadn't bothered to find out.
I said, What about paying? You said, I don't have any pay,
as I wanted to search and say we should have paid off an extra at that senior placement as a cost effective intervention.
But the clinicians involved had not ascertained what was really, really bothering the passion most.
And I got to speak mostly about population value because that's they had a working motive.
And I say that to estimate that forces allocated value and these actually derive from some of the economics that interest efficiency.
So if you look at how we allocate resources. Remember, health care is the most complex business on earth.
And we think someone, like most of us, we can disease as an example.
We spend about £100 million per million population on a variation of 1.8 fold.
From Somerset to Devon or from Leeds to Manchester. That's a violation of about £40 million.
And the decision makers hadn't even looked. No, they haven't done a lot of analysis out in the UK.
And then when you get into the budgets, if you see the discretionary budget,
you get bronchitis and asthma and you see about a huge variation due for people.
But no one's ever made these decisions. They haven't, even if you just help the economy or any other method to do it.
Then technical value for us is and this is where we differ from the Americans.
Firstly, we have to allocate resources from a finite budget to meet the needs of a whole population.
And secondly, when we've allocated resources to see people with atrial fibrillation or even in the last year of life,
we have to make the best use of those resources for all the people in need.
Now, the the issue here is all the people in need.
So the American definition is outcomes over costs for the patient is treated.
But we know that poor people get less hip and knee replacement than wealthy people.
So the fact that you're being very efficient and giving out cost effective treatment efficiently to
the people that you see doesn't mean that you're getting optimal value for all the people in need.
Because many people do the opposite broken legs. You see a lot of problems because they'll get in the right place.
Each cancer gets the right place to wait sometimes.
But. But things like knee pain, pain, asthma, psoriasis.
Once you get to the specialist centres are not the ones who would benefit most.
And then to find that budget, we have to shift resources from some of those.
So getting it. Just how much, you know. For example, we had a meeting for heart disease and the department and they opened a new contact clinic.
But you said all the referrals are from north of from Black Louise.
So these are all for cost effective interventions like. Sentiment, that sort of thing.
But there was a huge sugar rush in sports for you to predict.
The simple example of this population is getting 40 million times more spending in population being.
And how do you make the decisions? Well, firstly, health economics important.
But health economics alone can't do it as a wonderful bit of health.
It's called the possibility, if you like, that out of there is no there is no equation,
no matter how big your computer and how much data you've got, that'll be the same for you.
So the next thing is that they really do clinician and public health skills.
To ask, well, how big a problem is this really? What is the nature of this problem?
For example,
that we're now looking at a mushrooming of the treatment of people with genomic what's called a the US invitation of unknown significance.
So they hadn't got across that it was. But it's good because people have read about it and clinicians like doing it.
So we do think about how we manage that.
So indications involve when they need linguistics because simply seeing is something of value or not is in my experience,
you always lose that like attempted a hobby or university as well is much more valuable than.
Hip replacement or antidepressant or cataracts or hearing aids or distribution, because that's the trade off.
So you need linguistics and be careful not to be trapped into a simple definition of value or or effectiveness.
Then we need to think of ethics.
What principle should we allocate? Resources? How do we decide where to go from here?
You'll come up with what we call the hellish decision.
Someone will have to make a decision. Do we switch money from mental health to cancer?
From cancer to mental? From children or people or people.
Children. And there is no ethical principle utilities in terms of wonderful.
But the greatest gift to the greatest number means the least harm to a decent.
Many of the people with their diseases will suffer. And that means you're into politics and you have to understand politics and decision making.
So politics. Milton Keynes said there is nothing a politician likes so recklessly well-informed.
It makes decision making so complicated. And what is emerging is that the public know that these are hellish things we're trying to do,
use health, economics and epidemiology to try to do that. But there's always going to be people who suffer.
And the most useful concept by far is the concept of accountability for reasonableness.
The public are just wanting us to be reasonable not to let anyone subject to the population get its own way or through that biased information.
So health economics is of vital importance, but so is epidemiology, anthropology, linguistics, ethics, politics.
All of these things are involved in making decisions in the most complex business.
Thank you. But what should we do about this?
That's the question. How about we put some chairs on there and you sit close to each other?
This is a recording where you see everything you see is recorded. Yes, it is.
I just want to say, it's like, okay, okay. I've see what I'm going to do with protocol because I've never done one of these before.
So do that. I'm going to ask I'm going to allow you to ask questions of each other first.
Then I'm going to let you guys ask questions of these guys, and then we'll have a vote,
because I don't think it might help people clarify some things. Okay.
So have you got any questions for each other's talks about?
Anything you want to raise first and then I'll open up to the audience.
Yes, I have a question. So you talked about the whole collective and I sort of described that health can contain it.
It is it is a more recent development to consider it deeper, but it's that distribution of perspectives can do this.
And I think the key advantage of that is that you can.
Recognise the trade offs you're making. In this case.
So let's take an example of bowel cancer screening.
So that's a that's a classic inequitable. Screening program for people who are from the poorest communities,
do not send the samples and then they get with rates with all of the consequent problems that come with that.
But it costs a lot more to target your screening for those people.
And you don't you still there is good health outcomes.
So you have to pay more to target screening, recognising that in total you'll get worse outcomes.
How do you decide where that line is? We talked about optimising value across equity and efficiency as though it's obvious.
But it's not. There are times when you have to give up some of that efficiency for active post and post.
So how do you do that? Well, it's a it's called judgement.
And the question is, who makes the decisions? What we are doing increasingly is involving patients themselves and making decisions.
So if we were discussing bowel cancer screening and we try to make such a public in and that's not always easy, of course,
but it is possible that we complain about these clothes and our thoughts, and then we would say, well, where's the money going to come from?
So it I come from treatment for cancer, come treatment of other kinds of budget.
So do we want to spend less on chemotherapy because of maybe chemotherapy of marginal cost effectiveness
and reducing risk come in and should we switch money from there to increasing the prevention side?
And so some of it from than what I would call the colorectal cancer budget, that's where you get the most the decision.
But I would like these people here go without cancer and go to cancer just everyday with because there is no formula that will make that decision.
You can help us with providing the size of the weekly death rate.
And it comes down to. What do you think of your judgement about what the right leadership is?
So I start off and give you another example.
Let me try to face it so that you program for the majority of voters.
Say exercises for people with no. Now there you might want to visit Ferguson, but at least one protest in the city.
But where's the money will come from for that? But either it would come from somewhere else in the room.
We don't have to spend an I.V. asking us patients information, but it may be new information that might have to be explained.
That's why they seem to like it. So why they've got to come from somewhere.
And the more the member may not get, the more information he got, the more difficult the decision to break up.
So I lied to them and the public. I just thought, if you want us to make these decisions.
I think Ray Lewis is making very good points in the meantime.
I am. Everything seemed a logical patch on ideas and seeing new things, systematic reviews.
And though I read that that was this week, wasn't it?
Besides, he said that every every word will reach a point in time for it, causing more confusion and correcting yourself, using it.
So there will come a time when so many people use the word value, so many ways to show music.
So systematic review, which we all felt would be defined perfectly.
Joining, admitted that. Sure. And there were so many people using it.
So anyway, so it may well be that the term value is has come to the end of his life.
And I probably chose it because no one else is using it because something to pick out of it would have been better.
But it may not be the right one in the longer term.
So you see these data points who are interested to look at it and along the road and on the summit will be collecting on the validity value.
Well, any. What is your definition of value if you are it within the assessment?
Have you often have you optimised the allocation of resources?
What is optimal in life? Well, it vary from Somerset to Devon depending on what you've inherited,
because you're all inheriting different investments that people have never decided about.
So I want you to tell me you've looked at the budget, all of the people of Somerset, and you've come to a decision.
Well, this is the evidence which I made from one budget to another and get more value for the people.
So first part it's the first part of triple value. Then once we've allocated the money to people with.
COPD and. It then had to be asking how you really spend that money as well as you can.
Are poor people getting as much or maybe more than wealthy people?
Then you would say, Well, what about individuals and depressed individuals?
What they feel about the treatment. They hope the new job is cost effective.
But they may all be feeling very tired as a result of the treatment.
So they don't see the menu at all which doesn't these things what beans appear.
So the thethings I look at is. Should we allocate the money?
And then once I give you the money for rheumatoid arthritis or whatever, and then every individual will have their own going back.
So that's what I mean. That's what the fact is. And then further, what is an optimal allocation?
Well, not so now you just. And the circle of life continues.