Deliberative and Participatory Approaches in Health

1. Deliberative and Participatory Approaches in Health Dr Tim Taylor timothy.taylor@pcmd.ac.uk Prepared for the BRIDGE Values Workshop, London, 25th April 2012

2. Overview Structure Quick overview of NEA and health valuation Monetary valuation vs QALYs debate Deliberative monetary valuation in the health technology assessment Choice Experiments in the health setting Some thoughts on the CE vs DMV debate

3. NEA and Health Valuation Source: Pretty et al. (2011) Health Values from Ecosystems. Chapter 23 of UKNEA.

4. NEA and Health Valuation Methods Values not presented in monetary form in health literature generally – reflecting view of monetary valuation of health from a large proportion of health economists. Methods include: • Survey tools on self-esteem, mood state, mental well-being (e.g. General Health Questionnaire) • Physiological and questionnaire based methods for physical health – including BMI, blood pressure, cortisol • Questionnaires on connectedness to nature

5. NEA and Health Valuation Key issues raised More evidence needed on causality of health benefits from exposure to nature Potential for green exercise as therapy These are research issues that are attracting increasing attention – e.g. Blue Gym research agenda, but evidence base still needs development.

6. QALY vs monetary valuation How best to represent health? Quality Adjusted Life Years – ranking based on surveys about different conditions Monetary valuation of value of life year lost, cost of illness, social value of a QALY etc. Not something we are going to solve today – different metrics may be appropriate for different audiences and for different policy contexts

7. Health Technology Assessment NICE guidance on Health Technology Assessment Original remit of NICE: • Identify cost-effective technologies and make recommendations for their use in the NHS (generally ICER of £20k/QALY) • Create authoritative clinical guidelines to support cost-effective clinical practice in all health care settings NICE decision making on health care technologies is deliberative Draws on evidence on: • Context free clinical trials (and meta-analyses) • Context-sensitive cost-effectiveness analysis and social surveys • Colloquial evidence (e.g. experience of those around decision table) Deliberative process in coming up with guidance - weighing of evidence (Culyer, 2006)

8. Health Technology Assessment Use of deliberative methods for health Key issues relevant to “Values” workshop: • Consideration of uncertainty – assessment of risk and weight given is a matter of judgement • Other social and personal values that may become evident wither during assessment of evidence by expert advisory groups (e.g. systematic review), consultation and during discussions at appraisal. Existence and weight placed on them = matter for deliberation. • Health benefit measured in QALYs – though “cost-benefit analysis may be particularly useful when non-health consequences are important in an evaluation. In such cases, willingness-to-pay methods may be used to value all consequences in monetary terms” (NICE, 2004, cited in Culyer, 2006).

9. Health Technology Assessment Use of deliberative methods for health Ethics of distributive justice: • QALY = QALY in reference case, but… • “ethically relevant sameness” => treat the same or differently because of: • Pre- or post-treatment level of health • Current level of health • Age • Lifestyle This leads to a weighing up against cost per QALY threshold sets the social value against trade-offs for efficiency (Green, 2010). Kennedy report – set up over concerns on innovation: NICE guidance on social values “not above criticism”, with principles being sound but there being “too high a level of abstraction to provide real guidance, and the reasoning underlying them is not always as rigorous as it could be”.

10. Towards “Public” Values for Health Some argue existing methods do not properly account for public benefits of health e.g. Hausman (2010) argues: • Private evaluation of health states is not a good measure of public evaluation: • Preferences vs value of health states e.g. minor disability vs military service, drugs vs output in manic depression • Judgments of value require information, experience and time • Public value of health not aggregation of personal values e.g. coping with disability may lead to good QoL values, but if this drives public policy then may do less… • Suggests method of valuation around capabilities => “Social policy should aim to enlarge the possibilities for the successful pursuit of individual goals, rather than achieve those goals for individuals” (Hausman, 2010, p 286). • This leads to suggestion of use of activity limitation/feeling pairs, with deliberative groups and public debate to value.

11. Choice Experiments in the Health setting Choice experiments far more used in environmental context However, they have been used for Health Technology Assessment – and of course in valuing health benefits of the environment Are becoming increasingly popular in health care – e.g. have been applied to out of hours GP services and treatment characteristics (Drummond et al, 2005) Of relevance to the health values of ecosystems, few studies have used monetary methods to value mental health impacts – some have looked at major depression (e.g. Morey et al, 2006; Herbild et al, 2009).

12. Choice experiments in the Health setting Choice experiments and DMV: some thoughts Choice experiments may still offer useful insights into values: In the UK context, CE may be seen to be more realistic decision making environment • Experience of deliberative methods limited in UK compared to other contexts (e.g. history of “town meetings” in US and in other settings) • Values are derived from information provided and information held by individual “Joe Public” Settings for use of DMV generated and CE generated values may differ – DMV may be more appropriate for local issues than national perhaps… or for cases of large information asymmetries CE can be improved by better information provision on impacts. For health, monetary values are much less used – but it is arguable that in the ecosystems context, combining QALY impacts with monetary values may give more information to the decision maker.

13. timothy.taylor@pcmd.ac.uk • Thanks for listening