How do we achieve cost effective cancer
treatments in the UK?
Professor Peter Littlejohns
Department 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
constituents
To 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 Workshop
February 2011
Convened by Peter Littlejohns (KCL) Albert
Weale, (UCL)
Supported by Wellcome and Nuffield Trusts
Participants from:
Johns Hopkins University – USA
HAS – France
HITAP – Thailand
IQWIG – Germany
NECA – Korea
Renmin University – China
WHO
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?.....
The Courts
And accountability for what?
Patients
Clinical effectiveness
Value judgements
Meeting basic
entitlements
Priority
Setters
Health
professionals
Clinical effectiveness
Value judgements
Financial Expenditure
Cost effectiveness
Insurance payers
Taxpayers
Process Values: Participation
Who 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
Uncertain,
lack of
evidence, but
available –
solidarity?
Patients take
a risk –
autonomy?
 Only interventions that definitely
provide benefits
 Only interventions that definitely
provide benefit to patients, and
are better than available
alternatives
Certainty, good
evidence but
patients may
wait
Minimal risk
to patients –
paternalist?
Content Values: Cost-Effectiveness
How important is costeffectiveness, relative to
other values?
 It’s just one factor amongst many and
should not have privileged status
Strong focus
on individualrelated values,
eg. dignity
Who benefits
can be
important
 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
Less focus on
individual-related
values, more on
collective ones,
eg. opportunity
costs
Doesn’t matter
who benefits –
QALY is a QALY
is a QALY
Content Values: Justice/Equity
What might justice/equity require
in priority setting?
 All patients with the same condition
should be treated the same
Health is the
only relevant
factor
 Some patients should be ‘positively’ Factors other than
prioritised because of their status – eg.
vulnerable populations, the young, the health should be
taken into
poor, people with dependents
consideration
 Some patients should be ‘negatively’
prioritised because they are
responsible for their condition
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 socioeconomic solidarity;
Focus on individual;
autonomy important;
may factor in capacity
to benefit.
Content Values: Solidarity
What 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.
Priorities
set
collectively
 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
Launch of new programme
Future Research
English 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