Item — HN Reader

The best thing about NHS (from my perspective as a US person, although I lived in the UK for a while) is the use of QALYS to allocate budget, rather than spending huge sums on a small number of interventions at extreme cost and limited benefit. Has that focus shifted?

(My personal belief is there should be a level of universal medical care funded by some public entity, probably the nation state currently, but it should be capped at a relatively low level, probably closer to 1% of GDP and allocated on a QALYS and emergency or communicable biased, with private care in a relatively unregulated market outside of that. Probably would end up in the 5% range overall, but with universal access to basic and cost-optimized care and probably a wider variety of private, charity, experimental care.)

We should not spend excessively on medical care vs. other interventions -- it's absurd that in the US we can have homeless people on the street with extremely limited assistance on housing or lifestyle interventions, but as soon as they develop some medical condition, they get essentially unlimited much higher cost intervention to remediate those things, but still nothing to address the underlying cause. There are a bunch of cases where we could shift $1k out of medical spend for $10 in other spend and achieve a better outcome for the person and for broader society.)

3 comments

We still use QALYS. The problem is you don’t get to choose how much a given level of health care costs, and I think 1% of GDP is woefully inadequate. You spend about 4% of GDP just on Medicare alone.

As a US tax payer you pay about as much for Medicare, Medicaid and CHIP as tax payers in most developed countries do on health care in total. But then to actually get health care yourself you have to pay about the same again fir private health insurance.

I get private health care here in the UK through my employer. I pay for the NHS through taxes, and that’s actually how I and my family get most of our health care in practice. The private cover is basically a top up. If I use it I can get treatment more quickly, but at no cost to the NHS.

I think this is the best of both worlds. As a nation we get health care comparable to the US at half the cost, it’s truly universal so millions of people don’t fall out of the system. So I fully support the NHS, as a beneficiary of private health care I still think I and my family have got excellent value for money from it throughout my life. Private health care expands health care capacity, and reduces demand in NHS services, so everyone benefits. It may not see, ideal, but in practice I think it works very well, and frankly it’s how well it works that actually matters.

Currently the NHS is in rough shape, but this is mostly down to the flat economy since the financial crisis and the pandemic. Spending levels at the peak of the boom in 2008 were unsustainable whoever was in power.

>and I think 1% of GDP is woefully inadequate. You spend about 4% of GDP just on Medicare alone.

That all depends on the spending ROI. If the first 1% of GDP gets you 90% of the benefit and is universal, it may be just fine.

The problem is I don’t think it would. That logic just doesn’t scale. If one tenth of spending gave 90 of the benefit, then one hundredth of the spending should give you 90% of that, or about 80% of the benefit. That’s not how skilled labour intensive service costs work though. It’s probably more like one tenth of the spending would get you about 20% of the benefits. That’s certainly more efficient, but it’s just not going to be acceptable.

I think my example was extreme but is closer to the truth than yours. My realistic estimate would be perhaps 25% of the cost covers 90% of the benefit. Preventative medicine is cheap as is ending broken bones in children. What is really expensive is open heart surgery and three rounds of chemo for an elderly patient.

Cost x years of benefit really favors the easy interventions in the young.

Is the NHS using QALYs beyond drug treatments?

Is there a list somewhere of the QALYs for every intervention?

It becomes enough of a hot potato to say "drug X works, but not enough so we're not paying for it" because it lets you complain that the drug companies are charging too much.

But when you say "surgery X works, or 1:1 therapy works, but not enough so we're not paying for it", criticism now comes from both sides: the workers doing their job and the public.

Agreed...the biggest failure of "Obamacare" was not separating out a basic level of care as a minimum that all citizens get and requiring those kinds of plans be made available in every state.

Where I live I can only buy plans that include things like Chiropractic and Acupuncture and all kinds of other non-basic or catastrophic services. If I want a low-cost basic care + emergencies plan, I'm SOL.