“Health is bad for you. That’s what many economists believe” – Richard Horton, Editor of The Lancet
This kind of viewpoint crops up in almost all conversations health economists have with clinicians, but it couldn’t be further from the truth.
Evidence-based medicine is about using the best available evidence to improve medical decision making; giving patients better outcomes, and enabling them to live longer lives in good health. Health economics has exactly the same core purpose; using evidence systematically to inform medical decision making, with the goal of improving people’s health. While evidence-based medicine tends to focus on the choices an individual doctor or nurse makes, health economics is about the choices the health system as a whole must make. In a world of limited resources how do we decide what to prioritise, and what we can’t afford?
Economists love efficiency. It’s something that puts us at loggerheads with other professions who often mistake that efficiency for miserliness. But efficiency simply means getting the most of the outcome we want, given the constraints of budget and time. In traditional economics, this outcome is that ephemeral quality “utility”, which roughly equates to life satisfaction, also sometimes called welfare. In the UK, health economists take an “extra-welfarist” approach, with the outcome being health itself, rather than pure welfare. We use economic evaluations to work out how we can allocate the NHS budget to get the most health, across all possible options. Yes, we don’t want to spend £50,000 on a new cancer drug, but that’s because we can quantify exactly what that could have bought elsewhere, in vaccines, hip replacements or intensive care nurses.
Economic evaluations could be thought of as the ultimate evidence synthesis, synthesising not just outcomes, but their costs as well, allowing us to make a direct comparison between the health improvements that the treatment in front of us will provide, and the health provided by spending that money on something else. It’s decision making for the world we live in, rather than the one we’d like. Done well, it gives us the power to make people healthier and save money, by reallocating resources to the most effective treatments. Done poorly, it can bring a health system to its knees. The key point is that it is about making, and keeping, people healthier, not about saving money for its own sake, and certainly not about using health care for the benefit of the wider economy.
For this reason, the new Complex Reviews module of the MSc in Evidence-Based Health Care will include a health economics session. As people live longer, as chronic conditions become more prevalent, and as expensive new treatments are developed, budgets are being squeezed like never before. Complex decisions need to be made, and evidence-based health care must be at the forefront of this decision making. Understanding how systematic review informs economic evaluation will give students the tools to contribute to this vital, international conversation.
Lucy Abel is a Health Economist within the Nuffield Department of Primary Care Health Sciences, and teaches on Complex Reviews, a new course for 2017/18 as part of the MSc in Evidence-Based Healthcare. For further information, please click here.
Image courtesy of Ano Lobb.