Lucy Abel

Health economist in Oxford. Writing about health economics for non-health economists, and vice versa

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Has the NHS put the CAR-T before the horse?

CAR-T is going to be made available on the NHS for children who have an advanced form of a blood cancer, acute lymphoblastic lymphoma, that has not responded to other treatments. The BBC reports that an estimated 15 children a year will be eligible to receive the treatment, which works by extracting, editing and re-purposing the child’s own immune system. This treatment is exceptionally expensive, both for the drugs themselves and for the extra care patients require as a result. The treatment has been reported as costing upward of $300,000, with care costs topping $1 million in the USA. While care costs are usually substantially lower in the NHS, this will still be a very expensive treatment.

So if it is being made available on the NHS, does that mean it’s cost-effective? In a word, maybe. Realistically, probably not. Under the health economic model of cost-effectiveness, if the NHS...

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Value-based health care: just reinventing the cost-effectiveness wheel?

If you follow me on Twitter you will know that I have an ongoing curiosity for value-based healthcare (VBHC). VBHC is a relatively new approach to making decisions about health service provision. It is currently in vogue with local decision makers, largely, it seems to me, because of the advocacy of Sir Muir Gray’s research group on VBHC.

The VBHC Research Group’s illustration of the “Triple Value” framework

Because it is concerned with how to make decisions about healthcare provision, VBHC necessarily overlaps substantially with cost-effectiveness analysis, which is the approach advocated by health economists. VBHC breaks away from cost-effectiveness methods in more explicitly considering equity considerations (who benefits from an intervention, as well as just how much they do). It also discusses “personal value”, which seems to be largely about advocating for patient-centred care...

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HESG: an explanation, or, Why our conference is better than yours

Health economists know how to host a good conference. So much so that it inspires adulation on a level better associated with alcohol and comfort food. In fact, it briefly inspired its own meme.

So far I’ve not encountered any other academic fields who do something similar. This seems like a shame, so in the spirit of this evangelism I thought I’d provide a quick overview of what makes the...

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Charlie Gard and the harms of hope

The tragic story of Charlie Gard is now coming to an end, and with it some key information has been released by Great Ormond Street Children’s Hospital (GOSH), where Charlie is being treated.

The above tweet describes the most recent statement released by GOSH and its legal team, and the paragraph of interest runs as follows:

When the hospital was informed that the Professor had new laboratory findings causing him to believe NBT would be more beneficial to Charlie than he had previously opined, GOSH’s hope for Charlie and his parents was that that optimism would be confirmed. It was, therefore, with increasing surprise and disappointment that the hospital listened to the Professor’s fresh evidence to the...

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Nivolumab for head and neck cancer: why did NICE say no?

NICE has published draft guidance that an immunotherapy treatment, nivolumab, is not cost-effective for metastatic head and neck cancer. The guidance is still in consultation and therefore may change. But in the meantime the initial evidence has been published, so we can see what NICE’s reasoning was.


In this blog I’m going to take a look at what NICE has said and compare it with this news piece from the Institute of Cancer Research (ICR). I want to see what gets lost in translation.

The first thing I did when opening the appraisal consultation was to scroll straight down to the cost-effectiveness result. This section presents a variety of results, with the assumptions of each (poorly) explained. The results are presented as incremental cost-effectiveness ratios (ICERs). An ICER is simply the amount of money it would cost to get one unit of benefit from the new treatment. In this...

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The price of life? The good, the bad, and the ugly of valuing health

There is a certain kind of person I meet a lot at conferences. They’re often patient representatives - engaged, educated people who have dedicated enormous amounts of time to improving medicine for the people they represent. They often recognise the importance of health economics, but as a general rule they have one big issue with it: The QALY, and more particularly, the EQ-5D.

QALY stands for quality-adjusted life year, and it’s the main health outcome used in health economics, at least in the UK. As you’d expect, it’s a measure that combines length of life and quality, and mathematically it’s very straightforward. You multiply the length of life, say 5 years, by a quality adjustment, also called a health utility, that ranges between 0 (death - although scores can go negative, i.e., worse than death) and 1 (perfect health). So five years of some condition with a quality of life of 0.8...

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Reflections on “hellish” local decision making

The purpose of health economics is to spend the health budget as wisely as possible. In economic lingo, to maximise health within the constraints of limited resources. Nationally, we have been putting this into practice since before 1999, when NICE was set up. Locally, however, the picture is different.

This became apparent to me at the Hellish Decisions in Healthcare conference I was at in January, which brought together decision makers and decision informers, such as health economists and health services researchers, to consider the challenges facing the NHS, in particular at the local level, where decision making is still fairly ad hoc.

There are two big challenges that I see with local decision making. One is that the way local decision makers are organised isn’t compatible with national decision making, leading to inefficiency. Another is that pressure from patients for certain...

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Too much information? Weighing the harms of knowing everyone’s cancer risks

Screening, monitoring, and prophylactic (just-in-case) treatment of cancer is one of the big areas in medicine at the moment. The cases of Angelina Jolie and Ben Stiller have achieved their aims of raising awareness, but, as always, the health economist’s thoughts turn to “at what cost?”.

One problem with testing, particularly routine testing, which both of these celebrities have advocated, is not so much the possibility of finding something wrong, but instead of finding the potential for something. A genetic mutation, for example, that increases your risk of developing a certain cancer.

One of the risks of genomic testing is that you might find out you have a predisposition to a condition, such as Alzheimer’s, for which there is no cure. The consequences are obvious - there are no health benefits to knowing this, and the potential psychological harms are significant. Some patients...

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How do you value a ticking time bomb?

Photo credit: Oliver Dodd

Antibiotic resistance is a crisis waiting to happen. Widespread resistance would mean the end of most surgery and cancer treatments and the return of 1950s-style infectious diseases, complete with long-since forgotten child mortality rates. Much of the medical progress of the last 75 years would vanish, and yet for some reason almost nothing is being done.

We do know what needs to be done. Prescriptions need to be restricted to only cases where we have good evidence that they will work, and patients need to finish their courses of antibiotics in full, reducing the chances that the bacteria will survive the drug and go on to develop resistance.

We also need to change agriculture. Antibiotics are currently widely used in agriculture to improve livestock growth. Feeding animals a low dose of antibiotic prevents periods of sickness, increasing the short-term...

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Do we want to be precise… Or do we want to be useful?

The advantage of being in a department surrounded by non-health economists is that you get to hear all the opinions of health economics held by people who understand some, but not all of it. Clinicians, statisticians, etc. People who understand its applications but not its principles.

What I’ve learned from this is a greater understanding of where our communication falls down - that people don’t understand the cost-effectiveness threshold, or what a cost is, or why we count some values but not others when measuring health. Even if they can define a QALY and explain what NICE does, they don’t understand why. This won’t be surprising, but it should be. Our debates about health and costs should not be starved of the oxygen that is diversity of knowledge and experience. Understanding a health production function should not be a precondition to contributing to a debate on the value of...

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