Select Committee on Economic Affairs Minutes of Evidence

Examination of Witness (Questions 420-422)

Professor Sir Richard Peto

14 FEBRUARY 2006

  Q420  Lord Macdonald of Tradeston: In order to inform decisions about the allocation of limited resources, the Department of Health and NICE employed "quality adjusted life years". In doing that, the gain to a 75-year old is treated the same as the benefit to, say, a 20-year old: giving an extra year to a patient in very poor health is seen as yielding the same benefit as giving an extra year to a person with normal health. Does that seem logical and appropriate?

  Professor Sir Richard Peto: That is exactly what it avoids doing. The use of quality adjusted life years tries to give years different values, depending on how healthy the person is. If a person is not in good health, then a year of life not in good health is given somewhat less value than a year in good health. There is a discount, in that benefit in the distant future gets weighted somewhat less than benefit in the immediate future. That is arguable: you get much the same conclusions, however, with or without discounting. I think it is reasonable to try to say, "How many extra years are you gaining by this treatment, and, of those years, how many will be of a reasonable quality of life?". The use of quality adjusted life years tries to avoid exactly the problem that you raised. Avoiding the death of a 20-year old not only gains a lot more years of life than avoiding the death of an 80-year old, but in general those years will tend to be of better quality, human life being what it is. Attempting to quantify this is a sensible way of trying to proceed.

  Q421  Lord Skidelsky: As a supplementary, one does not want to carry that to any extreme, like weighting IQ, for example? I just wonder what the measures of quality are or are they mainly physical attributes and some alertness?

  Professor Sir Richard Peto: You can do the calculations with and without allowance for whether people are desperately miserable. If you just try to look overall, either globally or in particular countries, then in general the treatments that avoid death are those that produce big gains in terms of quality adjusted life years. The one mis-match is that if you do not put in some measure of the quality of life, then you underrate the relevance of musculo-skeletal disease and you underrate the relevance of various mental conditions. Roughly speaking perspectives based on what is most important in terms of quality adjusted life years, either globally or in particular countries, come out roughly like perspectives based on what is most important in terms of prevention of premature death. These two approaches match pretty well the things to which you would give priority. There are two things that do come out differently, however: mental illness gets seen as very much more important if you allow quality and also musculo-skeletal diseases get made relatively very much more important—although, actually, mental illness does cause quite a number of deaths worldwide. There are about one million deaths from suicide each year. In this country, suicide deaths outnumber traffic deaths. Suicide is a somewhat preventable cause of death: there are things one will do to reduce the likelihood of people dying by suicide. Returning to the main question, you can assess cost-effectiveness in various ways. It is surprising how robust the conclusions are. The approximate conclusion is that, apart from musculo-skeletal disease and mental illness, the things that are cost-effective for avoiding premature death are in general, much the same as the things that are cost-effective for gaining quality adjusted life years. Any such measure is imperfect. It has to depend on human judgment about the things you really value and the things you do not. But, use of quality adjusted life years does not seem to produce conclusions that seem to me widely wrong, in general, about the relative importance of things.

  Q422  Chairman: I think we ought to bring it to a close there. On behalf of the Committee, may I thank you very much indeed for coming along, and, if I may say so, setting a good example by indicating there was some degree of uncertainty in some of the things we are looking into. That is helpful to us in our general inquiry. We are very grateful to you for what you have said and the way in which you answered the questions. Thank you very much indeed.

  Professor Sir Richard Peto: Thank you for the opportunity.

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