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 health. We see this in other fields all the time - for goodness sake, recognising the contribution of non-experts is the entire basis for PPI, and, love or loathe it, its benefits are widely recognised.
But there’s more than this. The very nature of how we communicate our research requires economic knowledge. The mechanism for communicating research du jour is net monetary benefit. We take a universally understood value: health, and turn it into a price. Despite no-one understanding what a threshold means; despite no-one who does understand agreeing what that threshold should be in the first place; and despite the fact that we know people respond poorly to monetising health. It is a completely unintuitive way of representing health for anyone who is not already an economist.
And this has costs. If even clinicians don’t really get what the point of your numbers are, and you are dealing with a health system where clinicians are the predominant day-to-day decision makers, then surely you have a problem. The very way we calculate cost-effectiveness is inherently difficult for its primary users to understand. As a result, its primary users are not its users at all, instead we rely on an intermediary to proscribe from on high, and then are surprised when there is backlash from the people affected by these opaque decisions. And further, this then forces us back into our shells. Our work occasionally teeters on the edge of being truly useful for the health system we have, rather than the one we would like - value of information for the evidence we have; value of implementation for the, well, implementation we have. There are movements towards estimating the world as it is, rather than as we assume it is. But we have so far to go. We wonder at how decision makers disinvest from cost-effective treatments and provide no framework for them to make better decisions. We despair at the cost of “efficiencies” that are no such thing, but continue to value at the predetermined, evidence-free threshold.
The health economic literature, the blogs, the twitter streams are full of the precise language of economic theory. Hours upon hours go into trying to find the perfect definition for a specific health condition, and the purest consequence of a change in perspective. This is wonderful, interesting stuff; long may it continue. We are a field of applied researchers: the reason we try to nail down that perfect value is because it matters to patients. A bias in our analysis has a life or death consequence, somewhere down the line, for a person, or their mother, or child. We have a duty to get it right.
But we also have a duty to be understood. For the decisions we recommend to be taken up, the decision makers - the real decision makers; commissioners, GPs, nurses, patients, must understand why we have made them. In the era of value- and evidence-based medicine, when old truths are being questioned, and the curtain of the way things are done is pulled back to reveal that wizened old man, Habit, and nothing more, then we risk losing the fight we are all, in the end, fighting for: better health care, for more people, in the world as it is, in the hope that it might one day resemble the world we would like.