1 00:00:00,600 --> 00:00:03,899 Okay. Good evening, everyone. Thank you for being here. 2 00:00:03,900 --> 00:00:10,709 I see some familiar faces from the department and a few faces from not as many as I'd hoped from my module, 3 00:00:10,710 --> 00:00:14,220 but that hey, it's a, it's been a long day and some faces I don't recognise. 4 00:00:14,550 --> 00:00:21,810 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 5 00:00:21,810 --> 00:00:26,850 never hosted a debate and I've tried to stick to the Oxford rules or the Oxford Union rules, 6 00:00:26,850 --> 00:00:31,530 which I should describe to you. Believe me, there are rules you'll be probably unsurprised to know. 7 00:00:32,050 --> 00:00:36,090 But we've got a talk with a debate between a say between I don't know if it's between verses. 8 00:00:36,090 --> 00:00:40,649 I feel competitive, I thought, using these sorts of phrases. So I should be mindful of not doing that. 9 00:00:40,650 --> 00:00:48,810 But we're talking about value based health care and health economics repackaged, or is it a repackaging of health economics? 10 00:00:49,470 --> 00:00:56,129 And actually, the the the proposal has her own it's her own fault and herself to blame us for being here tonight, 11 00:00:56,130 --> 00:01:00,930 because she wrote a very interesting and provocative blog, which you should all go check out Lucy Abel's blog. 12 00:01:01,350 --> 00:01:10,020 And it started to spark this debate tonight. So Lisa will be proposing and some grey will be opposing for tonight. 13 00:01:11,280 --> 00:01:14,519 I shall just relay the rules to I'm not taking Twitter. 14 00:01:14,520 --> 00:01:19,350 I'm just on my phone relaying the rules I sent to the team for what we're doing tonight. 15 00:01:19,710 --> 00:01:27,930 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. 16 00:01:27,930 --> 00:01:34,200 So you may not interrupt or suggest or offer any inter interjections during those time periods, 17 00:01:34,200 --> 00:01:40,229 but any other time point you may I shall keep time and we have a bell. 18 00:01:40,230 --> 00:01:46,260 I'm I am to ring the bell every minute to inform you that a minutes has lost every minute. 19 00:01:46,380 --> 00:01:52,620 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. 20 00:01:52,620 --> 00:01:59,609 So you don't have to hear me shouting out caller every every minute you may offer points of information 21 00:01:59,610 --> 00:02:05,640 is what they're collectively you're technically called as a whilst your colleague is holding the floor, 22 00:02:05,850 --> 00:02:10,139 you can offer a points of information and usually no more than about 15 seconds 23 00:02:10,140 --> 00:02:13,920 please for these points of information and the speaker holding the floor, 24 00:02:14,130 --> 00:02:17,220 you may accept or reject them at your own, at your own will. 25 00:02:18,720 --> 00:02:25,560 At the end, I will let both speakers talk and then at the end we will have a vote. 26 00:02:26,130 --> 00:02:30,900 And then I'll open up to questions and we can discuss as to why we voted the way we voted. 27 00:02:30,900 --> 00:02:34,500 So who do we favour for or against? 28 00:02:35,280 --> 00:02:39,100 Is that everything clear? Any questions from the speakers? Nope. 29 00:02:39,640 --> 00:02:44,500 All right. Without further ado, then I shall hand the floor over to Lucy Abel. 30 00:02:46,710 --> 00:02:52,590 That wasn't good. Tell me when you're going to start ringing and picking me up. 31 00:02:52,650 --> 00:02:57,950 Can I have your hand back? Excellent. Let me know when to go. 32 00:02:59,020 --> 00:03:03,640 Time starts. Yeah. 33 00:03:04,000 --> 00:03:12,850 Okay. So the proposal before us is, is value based health care anything more than recreating health economics? 34 00:03:12,850 --> 00:03:15,940 And I'm going to argue that it first isn't. 35 00:03:16,360 --> 00:03:22,990 And second, it's attempts to do so will, in fact, result in worse patient outcomes in our health system. 36 00:03:23,470 --> 00:03:29,800 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. 37 00:03:30,490 --> 00:03:36,260 And the short answer to that is America. In the US over the last 20 years. 38 00:03:36,280 --> 00:03:42,990 Health care costs have exploded. And this has led to a renewed interest in health economics sort of approaches to try 39 00:03:43,000 --> 00:03:46,870 to contain some of those costs and ensure that the health system is being valuable, 40 00:03:48,040 --> 00:03:51,340 that the US doesn't really like cost effectiveness. 41 00:03:52,030 --> 00:03:58,090 There's an ethos of seeing it as rationing and therefore it's been rebranded and it's been called value based healthcare. 42 00:03:59,290 --> 00:04:06,550 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. 43 00:04:07,450 --> 00:04:11,050 And these constructs are all developed by health economists. 44 00:04:11,800 --> 00:04:15,450 There aren't value based health care advocates in the same way that there are in the UK. 45 00:04:15,460 --> 00:04:22,180 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 46 00:04:22,180 --> 00:04:28,870 and Neil has kindly written a number of articles explaining how value based health care works and how to find. 47 00:04:28,870 --> 00:04:35,560 And there are three key definitions that crop up allocated value, technical value and personal value. 48 00:04:37,540 --> 00:04:40,930 Excellent. I'm going to explain what these are. 49 00:04:41,260 --> 00:04:47,379 Explain why health economics already covers this ground and why the approach that value based healthcare is taking and redefining these is, 50 00:04:47,380 --> 00:04:57,070 in fact, worse. So let's start with elective value, which is all about allocating resources in a way that maximises equity and value. 51 00:04:58,030 --> 00:05:02,890 You're going to notice a slightly circular argument there that we can we can value to value value. 52 00:05:03,640 --> 00:05:07,360 And I've never seen a particularly good definition of value in value based health care. 53 00:05:07,360 --> 00:05:12,010 So I'm delighted that hopefully we agree, will give us a crystal clear, explicit definition of value. 54 00:05:14,380 --> 00:05:17,470 In health economics, we use the quality adjusted life year, they call it. 55 00:05:18,910 --> 00:05:25,410 It combines length of life data with quality of life data. It's based on public preferences for different health states. 56 00:05:25,420 --> 00:05:35,399 It's very well defined. We at least know what we're dealing with now in cost effectiveness analysis and in health economics. 57 00:05:35,400 --> 00:05:36,630 What health economics already does. 58 00:05:37,080 --> 00:05:42,510 You take your colleagues, you take your costs, you divide your colleagues by your costs, and you get a cost effectiveness ratio. 59 00:05:43,470 --> 00:05:47,960 This equation is also used in value based health care. It's been rebranded as the value equation. 60 00:05:47,970 --> 00:05:49,890 It is also quality over cost. 61 00:05:51,570 --> 00:05:57,510 Now, value based health care talked a bit more explicitly about using equity in a way that cost effectiveness sometimes doesn't. 62 00:05:58,560 --> 00:06:02,310 But you can use equity in health strategies analysis. You can bring equity into it. 63 00:06:02,910 --> 00:06:05,520 You can say, we're going to invest more in people with poor health. 64 00:06:05,970 --> 00:06:11,790 The key difference is that because we use the quality, because we have this cost effectiveness ratio, we know what we're giving up. 65 00:06:12,240 --> 00:06:18,389 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, 66 00:06:18,390 --> 00:06:23,560 you understand who is paying for that with their own health outcomes. You might still want to do it. 67 00:06:23,590 --> 00:06:28,330 It might still be really important because those gains for people with poor health are all really important. 68 00:06:28,690 --> 00:06:33,550 But you're paying for them with health outcomes and we understand that and we can justify it and it's transparent. 69 00:06:35,470 --> 00:06:39,140 So technical value. I don't know what technical value is. 70 00:06:39,160 --> 00:06:42,670 I have not seen a good definition for it. I'm really hoping we're going to get one today. 71 00:06:43,000 --> 00:06:48,070 It seems to be related to things like patient safety, health care efficiency, reducing waste, that sort of thing. 72 00:06:50,320 --> 00:06:58,240 The key question really is, are we maximising health with trying to achieve technical value if we're not maximising health? 73 00:06:58,780 --> 00:07:01,840 Why not? What what is this trying to achieve? 74 00:07:02,320 --> 00:07:09,040 Because any sort of patient safety initiative through a health economic lens will fundamentally come down to improving health outcomes for patients. 75 00:07:10,210 --> 00:07:15,940 The third definition is personal value. Personal value has a really lovely definition, which is that I've seen, 76 00:07:16,270 --> 00:07:22,580 which is using clinical expertise in combination with patient values based on the best available evidence. 77 00:07:23,200 --> 00:07:30,310 We're on an evidence based medicine course today. That is a textbook definition from Dave Sacca of evidence based medicine. 78 00:07:31,150 --> 00:07:34,540 So we have allocated value, in other words, cost effectiveness analysis. 79 00:07:34,540 --> 00:07:38,340 We have technical value, possibly also cost effectiveness analysis. 80 00:07:38,350 --> 00:07:42,760 If not, I'm not sure what it's for. And finally, we have personal value, which is evidence based medicine. 81 00:07:44,640 --> 00:07:46,790 Now in the UK, though, 82 00:07:46,800 --> 00:07:52,440 your best health care does seem to be trying to achieve something a little bit different from what health economics is trying to achieve. 83 00:07:53,100 --> 00:08:01,319 I've seen news of the startle and these value based healthcare interventions and I think 84 00:08:01,320 --> 00:08:04,680 they're worse than cost effectiveness methods and I think they're worse than health economics. 85 00:08:04,920 --> 00:08:09,690 The reason I think this is because I think that the goal is to make health economics more pragmatic. 86 00:08:10,290 --> 00:08:14,580 I think it's about trying to make it more amenable to decision makers. 87 00:08:15,310 --> 00:08:19,650 Bypass some of the most tricky decisions by only working within a particular budget, 88 00:08:19,650 --> 00:08:22,950 for example, and generally make the whole thing a little bit tidier. 89 00:08:23,670 --> 00:08:30,810 Health economics is really hard. Choosing between initiatives is really hard, and I think value based healthcare is trying to make it easier. 90 00:08:31,290 --> 00:08:35,340 I think that's bad. I think it reduces the ambition of the health care system. 91 00:08:36,300 --> 00:08:41,310 The reason I think this is to if you're working within the construction of the health system, 92 00:08:41,310 --> 00:08:44,280 if you're working within the way the budget is already allocated, 93 00:08:44,640 --> 00:08:51,570 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. 94 00:08:52,380 --> 00:08:53,370 So I'll take an example. 95 00:08:54,000 --> 00:08:58,890 There's a paradox in health economics that we're trying to reconcile at the moment, which is called cost effective but unaffordable. 96 00:08:59,610 --> 00:09:04,350 And it's what happens when cost effectiveness runs into budget impact analysis. 97 00:09:04,470 --> 00:09:10,230 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. 98 00:09:10,650 --> 00:09:18,210 These are highly cost effective. But they're not provided as widely as they should be because they eat up budgets. 99 00:09:18,330 --> 00:09:25,560 So many people have this condition and these aren't cheap treatments, but because they work really well, they're still cost effective. 100 00:09:25,860 --> 00:09:31,650 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, 101 00:09:31,740 --> 00:09:40,830 bureaucratic constraints of the NHS, what you end up doing is undermining that cost effectiveness, reducing the ambition, 102 00:09:41,280 --> 00:09:45,690 not trying to find ways of reorganising the health care system to provide these treatments. 103 00:09:46,350 --> 00:09:50,670 And I think that would, in the long term, result in worse outcomes for patients. 104 00:09:51,930 --> 00:09:57,690 So to sum up, qualities are measurable and understood. 105 00:09:57,900 --> 00:10:01,400 And they make sense. They're not easy, but they're transparent. 106 00:10:01,430 --> 00:10:06,770 We understand what they're trying to do. Value based health care has yet to define what value is. 107 00:10:07,770 --> 00:10:12,479 We don't know how it's going to respond to these questions of budget savings if it's 108 00:10:12,480 --> 00:10:15,480 going to be suitably ambitious in the way that cost effectiveness analysis is. 109 00:10:16,560 --> 00:10:23,730 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. 110 00:10:23,970 --> 00:10:29,160 And I think the value based health care risks undermining it in a way that will ultimately hurt patient outcomes. 111 00:10:30,290 --> 00:10:44,000 Thank you. Because of the technical transfer of microphones and what I see you've actually stuck to the official 7 minutes. 112 00:10:44,030 --> 00:10:49,879 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 113 00:10:49,880 --> 00:10:56,900 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. 114 00:10:57,320 --> 00:11:04,810 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. 115 00:11:12,970 --> 00:11:15,910 But one of the joys of working auction is the obsession with language. 116 00:11:16,810 --> 00:11:26,350 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. 117 00:11:27,010 --> 00:11:30,309 But he's moved on to Ebony or something else. Now I don't know what else. 118 00:11:30,310 --> 00:11:34,959 Do you spend the money working on each? So let me start with the definition and value based. 119 00:11:34,960 --> 00:11:38,050 Healthcare was invented in Oxford two years before America. 120 00:11:38,640 --> 00:11:42,190 I've been awfully good at talking about what they do, the Americans and very often health care. 121 00:11:42,190 --> 00:11:50,770 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, 122 00:11:51,360 --> 00:11:55,030 and we created three aspects about the first discussion. 123 00:11:55,970 --> 00:12:02,780 And. How is how is the outcome for this passion related to the problem that has bothered you the most? 124 00:12:04,160 --> 00:12:09,830 Subjective. You can measure the autonomy score, but we have to think what is bothering people. 125 00:12:10,760 --> 00:12:14,930 For example, I say I met a friend and they said, Would you come and meet my wife and myself? 126 00:12:15,680 --> 00:12:19,900 And they say, I need another business. And I said, okay. 127 00:12:19,950 --> 00:12:24,110 So I went to see him and I said, What's the problem? 128 00:12:24,320 --> 00:12:28,820 And he said, Oh, Patricia said. And his wife complains of walking peacefully. 129 00:12:29,710 --> 00:12:35,870 That's what changed your life. And she liked that situation very much and but they hadn't bothered to find out. 130 00:12:35,990 --> 00:12:38,450 I said, What about paying? You said, I don't have any pay, 131 00:12:39,350 --> 00:12:46,850 as I wanted to search and say we should have paid off an extra at that senior placement as a cost effective intervention. 132 00:12:47,630 --> 00:12:53,390 But the clinicians involved had not ascertained what was really, really bothering the passion most. 133 00:12:54,080 --> 00:13:01,210 And I got to speak mostly about population value because that's they had a working motive. 134 00:13:01,220 --> 00:13:08,990 And I say that to estimate that forces allocated value and these actually derive from some of the economics that interest efficiency. 135 00:13:09,890 --> 00:13:15,719 So if you look at how we allocate resources. Remember, health care is the most complex business on earth. 136 00:13:15,720 --> 00:13:19,650 And we think someone, like most of us, we can disease as an example. 137 00:13:20,490 --> 00:13:26,700 We spend about £100 million per million population on a variation of 1.8 fold. 138 00:13:27,900 --> 00:13:33,570 From Somerset to Devon or from Leeds to Manchester. That's a violation of about £40 million. 139 00:13:34,650 --> 00:13:39,520 And the decision makers hadn't even looked. No, they haven't done a lot of analysis out in the UK. 140 00:13:40,570 --> 00:13:44,950 And then when you get into the budgets, if you see the discretionary budget, 141 00:13:45,120 --> 00:13:51,120 you get bronchitis and asthma and you see about a huge variation due for people. 142 00:13:52,470 --> 00:13:57,060 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. 143 00:13:58,390 --> 00:14:02,070 Then technical value for us is and this is where we differ from the Americans. 144 00:14:02,080 --> 00:14:08,890 Firstly, we have to allocate resources from a finite budget to meet the needs of a whole population. 145 00:14:10,570 --> 00:14:17,800 And secondly, when we've allocated resources to see people with atrial fibrillation or even in the last year of life, 146 00:14:18,970 --> 00:14:22,840 we have to make the best use of those resources for all the people in need. 147 00:14:23,850 --> 00:14:27,150 Now, the the issue here is all the people in need. 148 00:14:27,930 --> 00:14:31,860 So the American definition is outcomes over costs for the patient is treated. 149 00:14:32,940 --> 00:14:36,600 But we know that poor people get less hip and knee replacement than wealthy people. 150 00:14:37,780 --> 00:14:43,389 So the fact that you're being very efficient and giving out cost effective treatment efficiently to 151 00:14:43,390 --> 00:14:48,670 the people that you see doesn't mean that you're getting optimal value for all the people in need. 152 00:14:49,540 --> 00:14:54,030 Because many people do the opposite broken legs. You see a lot of problems because they'll get in the right place. 153 00:14:54,040 --> 00:14:57,489 Each cancer gets the right place to wait sometimes. 154 00:14:57,490 --> 00:15:02,860 But. But things like knee pain, pain, asthma, psoriasis. 155 00:15:03,520 --> 00:15:07,390 Once you get to the specialist centres are not the ones who would benefit most. 156 00:15:07,690 --> 00:15:11,440 And then to find that budget, we have to shift resources from some of those. 157 00:15:11,440 --> 00:15:19,820 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. 158 00:15:19,840 --> 00:15:23,770 But you said all the referrals are from north of from Black Louise. 159 00:15:25,840 --> 00:15:31,650 So these are all for cost effective interventions like. Sentiment, that sort of thing. 160 00:15:32,160 --> 00:15:37,030 But there was a huge sugar rush in sports for you to predict. 161 00:15:37,050 --> 00:15:43,500 The simple example of this population is getting 40 million times more spending in population being. 162 00:15:44,360 --> 00:15:47,780 And how do you make the decisions? Well, firstly, health economics important. 163 00:15:48,560 --> 00:15:51,590 But health economics alone can't do it as a wonderful bit of health. 164 00:15:51,980 --> 00:15:56,300 It's called the possibility, if you like, that out of there is no there is no equation, 165 00:15:56,660 --> 00:16:01,460 no matter how big your computer and how much data you've got, that'll be the same for you. 166 00:16:02,450 --> 00:16:05,840 So the next thing is that they really do clinician and public health skills. 167 00:16:06,800 --> 00:16:10,970 To ask, well, how big a problem is this really? What is the nature of this problem? 168 00:16:12,210 --> 00:16:12,940 For example, 169 00:16:12,940 --> 00:16:21,630 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. 170 00:16:22,470 --> 00:16:29,190 So they hadn't got across that it was. But it's good because people have read about it and clinicians like doing it. 171 00:16:29,940 --> 00:16:31,600 So we do think about how we manage that. 172 00:16:31,620 --> 00:16:43,290 So indications involve when they need linguistics because simply seeing is something of value or not is in my experience, 173 00:16:43,290 --> 00:16:53,100 you always lose that like attempted a hobby or university as well is much more valuable than. 174 00:16:54,020 --> 00:17:00,080 Hip replacement or antidepressant or cataracts or hearing aids or distribution, because that's the trade off. 175 00:17:00,650 --> 00:17:06,800 So you need linguistics and be careful not to be trapped into a simple definition of value or or effectiveness. 176 00:17:07,940 --> 00:17:12,050 Then we need to think of ethics. 177 00:17:13,790 --> 00:17:18,550 What principle should we allocate? Resources? How do we decide where to go from here? 178 00:17:18,710 --> 00:17:21,770 You'll come up with what we call the hellish decision. 179 00:17:22,220 --> 00:17:26,920 Someone will have to make a decision. Do we switch money from mental health to cancer? 180 00:17:26,930 --> 00:17:30,780 From cancer to mental? From children or people or people. 181 00:17:30,780 --> 00:17:36,980 Children. And there is no ethical principle utilities in terms of wonderful. 182 00:17:37,580 --> 00:17:40,790 But the greatest gift to the greatest number means the least harm to a decent. 183 00:17:40,800 --> 00:17:51,620 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. 184 00:17:52,750 --> 00:17:57,820 So politics. Milton Keynes said there is nothing a politician likes so recklessly well-informed. 185 00:17:58,330 --> 00:18:07,240 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, 186 00:18:07,490 --> 00:18:12,660 use health, economics and epidemiology to try to do that. But there's always going to be people who suffer. 187 00:18:13,620 --> 00:18:18,600 And the most useful concept by far is the concept of accountability for reasonableness. 188 00:18:19,530 --> 00:18:28,500 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. 189 00:18:29,340 --> 00:18:37,350 So health economics is of vital importance, but so is epidemiology, anthropology, linguistics, ethics, politics. 190 00:18:38,100 --> 00:18:41,910 All of these things are involved in making decisions in the most complex business. 191 00:18:43,170 --> 00:18:52,250 Thank you. But what should we do about this? 192 00:18:53,150 --> 00:18:57,470 That's the question. How about we put some chairs on there and you sit close to each other? 193 00:19:01,580 --> 00:19:06,890 This is a recording where you see everything you see is recorded. Yes, it is. 194 00:19:06,950 --> 00:19:14,569 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. 195 00:19:14,570 --> 00:19:20,600 So do that. I'm going to ask I'm going to allow you to ask questions of each other first. 196 00:19:20,960 --> 00:19:24,800 Then I'm going to let you guys ask questions of these guys, and then we'll have a vote, 197 00:19:24,800 --> 00:19:28,010 because I don't think it might help people clarify some things. Okay. 198 00:19:28,760 --> 00:19:31,940 So have you got any questions for each other's talks about? 199 00:19:31,940 --> 00:19:35,270 Anything you want to raise first and then I'll open up to the audience. 200 00:19:36,290 --> 00:19:44,600 Yes, I have a question. So you talked about the whole collective and I sort of described that health can contain it. 201 00:19:44,940 --> 00:19:50,750 It is it is a more recent development to consider it deeper, but it's that distribution of perspectives can do this. 202 00:19:51,350 --> 00:19:54,920 And I think the key advantage of that is that you can. 203 00:19:56,260 --> 00:19:59,660 Recognise the trade offs you're making. In this case. 204 00:19:59,860 --> 00:20:03,310 So let's take an example of bowel cancer screening. 205 00:20:04,160 --> 00:20:12,050 So that's a that's a classic inequitable. Screening program for people who are from the poorest communities, 206 00:20:12,080 --> 00:20:18,020 do not send the samples and then they get with rates with all of the consequent problems that come with that. 207 00:20:18,710 --> 00:20:22,340 But it costs a lot more to target your screening for those people. 208 00:20:22,730 --> 00:20:25,850 And you don't you still there is good health outcomes. 209 00:20:27,290 --> 00:20:32,900 So you have to pay more to target screening, recognising that in total you'll get worse outcomes. 210 00:20:34,120 --> 00:20:42,310 How do you decide where that line is? We talked about optimising value across equity and efficiency as though it's obvious. 211 00:20:43,300 --> 00:20:47,770 But it's not. There are times when you have to give up some of that efficiency for active post and post. 212 00:20:47,980 --> 00:20:51,850 So how do you do that? Well, it's a it's called judgement. 213 00:20:52,090 --> 00:20:59,640 And the question is, who makes the decisions? What we are doing increasingly is involving patients themselves and making decisions. 214 00:21:00,460 --> 00:21:08,590 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, 215 00:21:08,590 --> 00:21:16,190 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? 216 00:21:16,210 --> 00:21:20,500 So it I come from treatment for cancer, come treatment of other kinds of budget. 217 00:21:21,250 --> 00:21:28,720 So do we want to spend less on chemotherapy because of maybe chemotherapy of marginal cost effectiveness 218 00:21:28,990 --> 00:21:35,530 and reducing risk come in and should we switch money from there to increasing the prevention side? 219 00:21:35,950 --> 00:21:43,269 And so some of it from than what I would call the colorectal cancer budget, that's where you get the most the decision. 220 00:21:43,270 --> 00:21:51,040 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. 221 00:21:51,070 --> 00:21:55,629 You can help us with providing the size of the weekly death rate. 222 00:21:55,630 --> 00:22:01,040 And it comes down to. What do you think of your judgement about what the right leadership is? 223 00:22:01,730 --> 00:22:05,600 So I start off and give you another example. 224 00:22:05,600 --> 00:22:08,930 Let me try to face it so that you program for the majority of voters. 225 00:22:10,440 --> 00:22:19,510 Say exercises for people with no. Now there you might want to visit Ferguson, but at least one protest in the city. 226 00:22:20,260 --> 00:22:26,479 But where's the money will come from for that? But either it would come from somewhere else in the room. 227 00:22:26,480 --> 00:22:33,760 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. 228 00:22:34,400 --> 00:22:38,030 That's why they seem to like it. So why they've got to come from somewhere. 229 00:22:38,030 --> 00:22:44,510 And the more the member may not get, the more information he got, the more difficult the decision to break up. 230 00:22:44,960 --> 00:22:52,010 So I lied to them and the public. I just thought, if you want us to make these decisions. 231 00:22:53,890 --> 00:22:58,129 I think Ray Lewis is making very good points in the meantime. 232 00:22:58,130 --> 00:23:06,280 I am. Everything seemed a logical patch on ideas and seeing new things, systematic reviews. 233 00:23:06,280 --> 00:23:08,710 And though I read that that was this week, wasn't it? 234 00:23:09,580 --> 00:23:17,110 Besides, he said that every every word will reach a point in time for it, causing more confusion and correcting yourself, using it. 235 00:23:17,110 --> 00:23:22,350 So there will come a time when so many people use the word value, so many ways to show music. 236 00:23:22,490 --> 00:23:25,570 So systematic review, which we all felt would be defined perfectly. 237 00:23:26,080 --> 00:23:28,510 Joining, admitted that. Sure. And there were so many people using it. 238 00:23:28,570 --> 00:23:33,670 So anyway, so it may well be that the term value is has come to the end of his life. 239 00:23:33,670 --> 00:23:40,320 And I probably chose it because no one else is using it because something to pick out of it would have been better. 240 00:23:41,410 --> 00:23:43,770 But it may not be the right one in the longer term. 241 00:23:43,780 --> 00:23:55,510 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. 242 00:23:55,950 --> 00:24:01,340 Well, any. What is your definition of value if you are it within the assessment? 243 00:24:01,360 --> 00:24:05,080 Have you often have you optimised the allocation of resources? 244 00:24:05,560 --> 00:24:11,680 What is optimal in life? Well, it vary from Somerset to Devon depending on what you've inherited, 245 00:24:11,680 --> 00:24:15,490 because you're all inheriting different investments that people have never decided about. 246 00:24:16,270 --> 00:24:22,900 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. 247 00:24:23,980 --> 00:24:30,100 Well, this is the evidence which I made from one budget to another and get more value for the people. 248 00:24:30,750 --> 00:24:36,880 So first part it's the first part of triple value. Then once we've allocated the money to people with. 249 00:24:38,360 --> 00:24:46,220 COPD and. It then had to be asking how you really spend that money as well as you can. 250 00:24:46,240 --> 00:24:50,380 Are poor people getting as much or maybe more than wealthy people? 251 00:24:51,430 --> 00:24:54,490 Then you would say, Well, what about individuals and depressed individuals? 252 00:24:55,470 --> 00:24:59,940 What they feel about the treatment. They hope the new job is cost effective. 253 00:25:00,850 --> 00:25:04,930 But they may all be feeling very tired as a result of the treatment. 254 00:25:05,540 --> 00:25:09,090 So they don't see the menu at all which doesn't these things what beans appear. 255 00:25:09,110 --> 00:25:12,230 So the thethings I look at is. Should we allocate the money? 256 00:25:12,290 --> 00:25:19,680 And then once I give you the money for rheumatoid arthritis or whatever, and then every individual will have their own going back. 257 00:25:19,760 --> 00:25:24,800 So that's what I mean. That's what the fact is. And then further, what is an optimal allocation? 258 00:25:25,550 --> 00:25:30,990 Well, not so now you just. And the circle of life continues.