How do we achieve cost effective cancer treatments in the UK?

Professor Peter LittlejohnsDepartment of Public Health and

Primary Care

Summary of talk – 3 key themes

• The question is not should you prioritise health care ...... but how to.

• Rarely is there a “right “ answer..... so how you get to the answer is important

• The role of the patient and the public is crucial to the whole process

The Nature of Evidence

Judgements have to be made

The role of social values

Evidence based guidance can be viewed as a practical manifestation of social contracts in deliberative democracies to ensure the most efficient and ethical allocation of finite healthcare resources to its constituentsTo achieve its goal, social values as well as technical issues need to be considered and should reflect the social/political milieu in which the organisation exists

NICE’s Response

Involving the public through the Citizen Council

http://www.radcliffe-oxford.com/

Future Research Agenda in Social Values and Patient and Public

Involvement

First International WorkshopFebruary 2011

Convened by Peter Littlejohns (KCL) Albert Weale, (UCL)

Supported by Wellcome and Nuffield TrustsParticipants from:

Johns Hopkins University – USA HAS – FranceHITAP – ThailandIQWIG – GermanyNECA – KoreaRenmin University – ChinaWHO

Conclusions of workshop

• Lots of people telling you what you should do to achieve fair prioritisation of health care but very few tell you how to .

• Need for a new “practical” international research and policy network

• Goal is to develop a prioritisation tool kit for policy makers and patients and the public in support of prioritising health services fairly

Social Values Framework

The processes of decision making Institutional setting Rules of decision making Accountability for decisions

Participation in decision making

The content of decision making Cost and clinical effectiveness Social value judgements Cost-sharing

Process values: Transparency

How might we define transparency?

Everyone knows who makes decisions

Everyone knows who makes decisions and by what processes

Everyone knows who makes decisions, by what processes and for what reasons

Basic transparency of

institutional arrangements

Transparency of institutional

decision making processes

Full transparency of institution, processes

and criteria

Process Values: Accountability To whom is accountability owed?.....

And accountability for what?

Priority Setters

Clinical effectivenessValue judgements

Patients

Clinical effectivenessValue judgements

Health professionals

Financial ExpenditureCost effectiveness

TaxpayersInsurance payers

Meeting basicentitlements

The Courts

Process Values: ParticipationWho might participate? Patients, health professionals, experts, taxpayers, insurance payers, citizens….

Why value participation?

If people have their say, then they can’t complain at the result

Decisions are more legitimate if different interests can contribute

It improves the quality of decisions Those whose money is being spent

should have a say in what it’s used for

The more of these reasons apply, the

more we move from consultation to

control.

Content Values: Clinical Effectiveness

How to define clinical effectiveness?

Any intervention showing some evidence of benefit

Only interventions that definitely provide benefits

Only interventions that definitely provide benefit to patients, and are better than available alternatives

Uncertain, lack of

evidence, but available – solidarity?

Certainty, good evidence but patients may

wait

Patients take a risk –

autonomy?

Minimal risk to patients – paternalist?

Content Values: Cost-EffectivenessHow important is cost-effectiveness, relative to other values?

It’s just one factor amongst many and should not have privileged status

It’s one of the most important factors but not always decisive – however it might be unusual for other values to over-rule it

It’s of primary and decisive importance

Strong focus on individual-related values,

eg. dignity

Less focus on individual-related values, more on collective ones, eg. opportunity

costs

Who benefits can be

important

Doesn’t matter who benefits –

QALY is a QALY is a

QALY

Content Values: Justice/EquityWhat might justice/equity require in priority setting?

All patients with the same condition should be treated the same

Some patients should be ‘positively’ prioritised because of their status – eg. vulnerable populations, the young, the poor, people with dependents

Some patients should be ‘negatively’ prioritised because they are responsible for their condition

Health is the only relevant

factor

Factors other than health should be

taken into consideration

Factors other than health should be

taken into consideration

Treats all individual patients the same; expresses health solidarity;

May consider people other than patient; may express socio-economic solidarity;

Focus on individual; autonomy important; may factor in capacity to benefit.

Content Values: SolidarityWhat might solidarity

require?

All have access to ‘comprehensive care’, however defined

All have access to a ‘basic package’, however defined

Entirely private arrangements

Full social solidarity

Partial solidarity

Weak solidarity

Content Values: Autonomy

How important is autonomy? Autonomy as personal preference and personal

responsibility

We should give low priority to individual preferences, and individual responsibility should not condition access to treatment.

People should be able to exercise some preferences over some care

People are responsible for spending their own money and for their own lifestyle choices

Individualistic focus for priorities

Priorities set

collectively

Launch of new programme

Future ResearchEnglish Project

As part of a new international research programme exploring the role of social values in health policy decisions we propose to test an emerging social values framework with the clinical commissioning groups. The aim is to develop and evaluate a social values, patient and public involvement tool kit to support CCGs in their responsibility to prioritise and comssion health care.

The project will consist of 3 phases:

(i)The draft social values framework will be introduced into a few localities in order to test its face validity, applicability and to explore potential methods and metrics to assess its impact.

(ii)Develop a social values, patient and public involvement tool kit (SVPPIT)

(iii)Test SVPPIT in a national study and evaluate its impact.

Thank you for your attention