What is a sea view worth? According to a holiday brochure just received, the answer seems to be £6.44 a night, because the supplement for an ocean view cabin for a 9 night cruise of the Greek islands is £58. On the other hand, it’s also £58 for 5 nights in the Norwegian fjords, so presumably the Norwegian coast is 1.8 times as desirable. Whether that is actually the case depends on whether our assessment of the value of these experiences tallies with the cruise companies. If it is, we’ll pay the extra. If we think it isn’t, we don’t. As a tall person, I don’t often think the extra legroom seats are good value on short flights, but there’s a price I am willing to pay on long ones. Even then, I draw the line at paying an extra £150 each way, but I’ve paid £60.
This is an example of the difficulty of comparing the value of benefits when they are not expressed in cash, and it is a major problem for healthcare, because when we make business cases for interventions we commonly have to reduce everything to money and pose the question “Is this a good use of resources?” This process might work if judgements were objective, but often they are not. For example, the value of saving the sight of an eye depends upon whether it is the first or second eye. Should we be prepared to spend more on treating the hand of a concert pianist than a roadmender?
The standard NHS approach is to use Quality Adjusted Life Years, or QALYs. This a good attempt to reflect that extending a life is less valuable to some than others, but it has limitations. There are some people whose quality of life is so bad that they would objectively be better off dead; that is, a QALY value <0. And back in 1987 John Harris pointed to a concern about the way in which we use QALYs that he called the double jeopardy. His argument was that if someone is disabled such that they will never again have a QALY of 1, they will be disadvantaged in any resource allocation based on QALYs because they can never benefit as much as the rest of us, although a move from 0.2 to 0.3 may make more of a difference to those patients than a move from 0.7 to 0.9 in others. The counter argument is that we should be rating the expected improvement of an intervention regardless of prior impairment and comparing it with other interventions on the same basis, so the starting point of any particular patient is irrelevant. And the counter argument to that is that if the entire class of patients requiring a particular intervention are starting from a low base it may be that no intervention for them will pass the benefits threshold that sees them introduced.
In the next series of the PM Academy we’ll be looking influencing decision making. This is not just about influencing the things that affect us personally. How we demonstrate value in the things that we care about and do is also an issue.