PHREE Spring Conference 2014

1. By
Alan Maynard
Email: alan.maynard@york.ac.uk

2.  Introductory issues
 The production of health
 Types of poverty
 Scarcity, ethics and economics

3.  Please contract scepticaemia and let it affect
every aspect of your work!
 Scepticaemia is defined “an uncommon
generalised disorder of low infectivity.
Medical school education is likely to confer
life-long immunity”
 Source: Skrabanek and McCormick, “Follies
and Fallacies in Medicine” 1989

4.  “the philosophers have only interpreted the world
in various ways; the point is to change it”
(Karl Marx, Theses on Feuerbach (1845))
 The purpose of public health is to provide
evidence to pursue the social goals of efficiency,
equity and expenditure control in health
production and distribution
 Public health is a subject not a discipline
 A subject like public health uses disciplines such
as sociology, psychology, statistics and
economics to explain society using testable
hypotheses.

5.  The production of health is determined by many
inputs, of which health care is one
 An important policy problem is to determine
which inputs improve health the most at least
cost: the efficiency or cost effectiveness
challenge
 Then given our interest in inequality, there is a
need to identify the impact of efficient health
production policies on the distribution of health,
and whether efficiency has to be foregone to
improve equity
 The role of health care ……….

7.  “ I once asked a worker at a crematorium, who had
a curiously contented look on his face, what he
found so satisfying about his work. He replied that
what fascinated him was the way in which so much
went in and so little came out. I thought of advising
him to get a job in the NHS, it might increase his
job satisfaction, but decided against it. He probably
gets his kicks from the visual demonstration of the
gap between input and output. A more statistical
demonstration might not have worked so well.”
 Archie Cochrane, “Effectiveness and Efficiency”
(1972)

8. Income
Wealth
Nutrition
Sanitation
Education
Housing
Work
Leisure
Genetic
endowment
Health care
Health
capital
stock
Healthy
days / years
of life

9.  Is income inequality a major determinant of good
health? If so policy design must be careful:
◦ Cross sectional poverty i.e. how many are living in
poverty today? What social security/fiscal policy to use?
◦ Life cycle poverty i.e. what is your experience of poverty
over your life?
 e.g. Rowntree’s analysis of life cycle poverty in York in 1899:
 born into poverty, relative affluence after school and pre-
marriage, more poverty when married and rearing children,
relative affluence after children leave home and still
employed, poverty in old age.
◦ Life cycle poverty now? Policy options?

10.  Inter-generational poverty
◦ i.e. do the poor children of one generation inherit
the deprivation of their parents?
 E.g. “Income in Two Generations” (Atkinson,
Maynard and Trinder (1983)
◦ Evidence of limited income mobility between
generations, with education (years of school) the
major determinant of improved income status

11.  Not sufficient to answer “income redistribution”
or “education”
 Need to identify the form of “income” distribution
(e.g. the mode child benefits and pensions?)
 Need to identify the form of “education” (e.g.
pre-school to develop play and attention skills
gives a better rate of return than teenage
interventions) .
 Need to identify life cycle effects of early
interventions (e.g. Heckman et al, Science
3/2014)

12.  Identifying “effect” alone is a necessary but not a
sufficient condition to invest in health production
 Economics starts from the assumption that
resources are limited and that scarcity affects the
behaviour of all individuals and institutions
 Scarcity obliges us to make choices
 Each choice we make involves an opportunity
cost
 The opportunity cost is the value of what we give
up when we make a choice

13.  Investing in health care and other ways of
producing health involves opportunity costs
 A decision to treat my cancer deprives other
patients of care which would increase the length
and quality of their lives
 Rationing involves depriving patient of care from
which they could benefit, and that they wish to
have
 Investing in health production locally to reduce
smoking, teenage pregnancy and car pollution
means less is available for social care
 Every investment action by individuals and
institutions involves an opportunity cost

14.  Willingness and ability to pay= deprive the poor
 Random allocation: the second Oregon
experiment (NEJM, 2013)=deprive those who lose
in the lottery
 Personal characteristics e.g.
◦ Age: the fair innings approach
◦ Gender and marital status
◦ Religion
◦ Mental health and learning difficulties
◦ Education
◦ Use of addictive substances e.g. tobacco and alcohol
◦ Personal characteristics e.g. weight

15.  Which investment gives you “the biggest bang
for the buck” in terms of producing
improvements in the length and quality of life
of citizens (QALY)?
 “what is clinically effective may not be cost
effective, but what is cost effective is always
clinically effective” (Maynard, Lancet, 1998)

16.  Hippocratic oath focuses on benefit, and ignores
opportunity cost
 To economists this individual perspective is
unethical
 They emphasise the social perspective i.e. in
health care resources are limited to circa £110
billion.
 The imperative is to maximise health
production/improved patient outcomes from that
fixed budget.
 Allocation of care should be based on “need”
defined as those who benefit most at least cost:
the cost effectiveness rule

17.  Inefficiency is unethical as it deprives
potential patients/citizens of care/preventive
activities from which they could benefit

18. 1. Cost to the NHS/public provider?
2. Cost to the patient/citizen?
3. Costs to the carers of patients/citizens?
 Technology appraisals (TAs) by the National
Institute for Health and Care Excellence (NICE)
includes only costs to the NHS

19. 1. Benefits to the patient/citizen?
2. Benefits to the carers?
3. (external benefits i.e. the effects on your
quality of life of your best friend’s health
improving? )
 The National Institute for Health and Care
Excellence includes only the benefits to
patients in their TA work

20.  NICE’s perspective is determined by
legislation
 Patient groups and the pharmaceutical
industry seek inclusion of “societal benefits”
 Quality of societal data is poor.
 Need to put QoL measurement for carers into
trials?
 An example of the effects of competing cost
and benefit perspectives: programme of
getting children to walk to school: what costs
and effects to include?

21.  Inadequate attention to cost effectiveness
 Evaluation of health production investments
that ignore the economic approach exposes
practitioners to being ignored, and perhaps
even ridiculed

22.  In health care for instance the efficiency rule is
discounted because of equity/social goals e.g.
low birth weight babies
 Tackling inequalities in health using the cost
effectiveness approach could identify the
interventions that advantage the more affluent
rather than the poor e.g. advice on smoking?
 Thus essential to identify the distribution of
costs and effects.
 Would there be social support to weight QALY
gains in favour of the poor?

23.  Living wage (Pickett)
 Early childhood (Melhuish)
 Replace 30 mph speed limits with 20mph limit (Dorling)
 “Health first” approach to tackling worklessness (Bambra)
 “Participatory budgeting” in mental health (McKensie)
 Further and adult education (Chandola & Jenkins)
 Improve employment conditions for public sector
workers (Nazroo)
 “Age friendly” environments for older people (Hendig &
Phillipson)
 Source: “If You Could Do One Thing…: local actions to
reduce health inequalities”, British Academy, 2014

24. 1. Resources are limited, and evidence of the cost
effectiveness of competing interventions to
reduce health inequalities is essential
2. Investments that are efficient may not reduce
inequality
3. If efficiency has to be given up to reduce
inequality, the opportunity costs of such
choices should be explicit
4. Such explicitness can ensure accountability and
good governance of society’s scarce resources
 Good luck in your work but expect problems…….

25. We should be kind to all people,
even those who are vested with
authority, but we must be ruthless
in seeking and criticising the evidence
on which their beliefs are founded
Skrabanek & McCormick 1992