Editor's Blog 12th October 2008: the repricing of NICE advice, and new Maynard Doctrine

Good morning. I hope this finds you well in our new socialist utopia.

What fun to own shares in banks! Presumably, this is sharing the proceeds of negative growth? Now, when do we start finding out about our year-end bonuses, and dropping heavy hints to the Revenue that we'll move abroad if they're not good enough?

Still, it has to be done.

New on the site today is the latest instalment of the Maynard Doctrine, which looks at the potential and the pitfalls around incentivising quality. In a recession-time economic and political situation, doing more with less is going to be the name of the game. As revealed yesterday, the 2009-10 financial year is probably going to be re-opened and spending for all departments - including the twin totems of health and education - revised downwards.

But great care is always needed when making cuts. Ask any good surgeon. Crucially, this means that prevention and outcomes become even more important.

Cost-effectiveness is, equally, going to become even sexier. The Independent On Sunday revealed yesterday that new research, commissioned by NICE and due out in Health Economics this week from Helen Mason and colleagues at Newcastle University suggests that the QALY figure of around £30,000 a year is at variance with the public's values on a healthy year - which range between £35,000 and £70,000 a year. The research criticises the lack of impact of public opinion on the NICE system.

The IOS also highlights another new study by Paul Dolan, professor in health economics at Imperial College, suggesting that NICE judgments do not reflect the extended impact of ill-health on patients and their families. Dolan is reported to suggest "that the public wants Nice to consider age, type of illness and, most controversially, the extent to which patients themselves, or the NHS, must bear some of the blame", and as saying, "allocating money on the basis of what conditions people fear most means resources are not going where they are most needed. We need a QALY, but it needs to change so we can measure the misery of sufferers and carers directly.

"Society wants to us to weight QALYs for people with limited lifetime health prospects. But they also want us to tweak this a bit depending on who they feel is responsible for the suffering. Culpability is tricky and controversial but these value judgements already go on implicitly, for example, when doctors decide which patient should get the liver transplant."

Hmm. If this thinking prevails, we will fast be returning to the need to differentiate between the deserving poor and the undeserving poor. Whom do we blame for the broader determinants of health? It's almost reminiscent of Charles Clarke's hilariously rubbish paper for KPMG.

There is a piquant irony that just as we taxpayers bail out the clay-footed City, the suggestion that we should blame the poor and ill-educated for their ill-health rears its head.

The American dream
Meanwhile, following up from Tom Smith's Health Policy Today last week on the issue of healthcare in the US election), Professor Ted Marmor of the University of Yale has kindly sent me a link to his piece in the Philidelphia Observer.

Written with his colleague, law Professor Jerry Mashaw, Marmor points out that for US citizens, "Insurance coverage and the cost of care are the leading problems. The candidates' approaches to each reveal fundamental differences on how to expand insurance, and superficial similarities on how to control costs."

You should read the feature: it is both short and excellent. But your heart might sink as mine did to read about both candidates' "repeated appeals to the substantial cost savings that better information technology can bring. If we just had better clinical research and electronic medical records, the theory goes, we could save billions by paying only for what works, helping doctors learn what that is, and avoiding mistakes".

Dear oh dear. It's what Robert Evans calls a policy zombie.

As Marmor and Mashaw put it, "as answers to the persistent inflation in medical prices, private-insurance premiums, and government health expenditures, they reflect wishful thinking. They rest on aspiration, not established cost-control practice ... Really controlling costs requires restraining salaries in the healthcare industry. It's a controversial task, not a fashionable platitude."

Amen to that.

And speaking of US policy zombies, did you know that Harry and Louise made a comeback?

The CBS story reports that 'at a recent press conference, the same health insurance lobby that paid out $17 million for Harry and Louise to defeat the Clinton plan now says it supports the idea of universal coverage and likes the new ad campaign. "It's a different time," said Karen Ignagni, president of American Health Insurance Plans. "Our community believes it's very important to move on an agenda of health care reform." "I think it shows that the American people are coming together," said Ron Pollack, executive director for Families USA Patient Advocate Group. "Those who were opposed to health care reform in the past now know it's critically important." '

You can enjoy the new Harry and Louise ad here.