Jennifer Hislop: Florence Nightingale and Mae West – the unsung pioneers of health policy?

Jennifer HislopThe second part of the session “Investing in health. From health to wealth” at the European Health Forum Gastein was devoted to “Resolving the efficiency and quality dilemma.” Olivia Wigzell, Deputy Director General of Health and Social Affairs in Sweden, spoke eloquently on the topic of health systems performance assessment (HSPA), citing Florence Nightingale as an early pioneer. Not only did Nightingale evaluate the effectiveness of performance during the Crimean War, she also used visual methods of describing her statistics to articulate the problems clearly and so aid politicians in their decision making. We can only wonder what Florence Nightingale would have achieved with PowerPoint at her fingertips. Things are of course different now and perhaps she would have lost her zeal for statistics if it had been policy to collect key performance indicator data?

The obvious benefits of HSPA were extolled—identifying areas of excellence, success, failure and variation compared with other areas; driving improvement; and promoting accountability. Wigzell noted, however, that the EU could be more visible in this area. While it is active in developing and collecting indicators, the WHO and OECD are more visible, and in fact it’s the OECD data people turn to in order to compare health systems. Other challenges in this area include the need for consistency, the trade off between timely and regular reporting, and the necessity of making sure that it’s feasible for member states to collect data. There is also a need to make sure that those member states who are collecting data understand why it is needed at EU level, why it takes so long to compile, and what the payoff will be for them in the long run.

Rosanna Tarricone of CeRGAS at Bocconi University in Italy spoke about the limitations and challenges of Health Technology Assessments (HTAs). Her first point was about the source and quality of evidence used to inform HTAs. Now that the potential for using big data is on the horizon, the RCT—our gold standard of evidence—is in danger of having its limitations laid bare: the impracticalities of blinding in situations, the strict inclusion criteria, or the use of potentially undesirable (to patients being recruited) comparators. Tarricone argued this can mean sometimes in HTAs we don’t really know what we’re comparing, although surely a quality assessment process would give any HTA an indication of how far to trust included data.

The timing of HTAs was also raised as an issue—too early and the evidence base is not fully developed, too late and the technology under review has already been superseded by others. Timely access is warranted for patients of course, but Tarricone highlighted the need to ensure protocols are designed so that decision makers get the evidence for the question they want the answer to, and not the only answer available because it’s all the data we’ve got.

Mae West was briefly credited with inventing the QALY, although according to Google she adapted Abraham Lincoln’s “it’s not the years in your life that count but the life in your years” and applied it to the men in her life. In any case I’m sad to report to fellow health economists that this joke shows no signs of being retired anytime soon.

The lack of harmonisation across member states was noted. Tarricone showed that different methods and inclusion criteria for HTAs can yield different answers to the same question, although in part at least this probably goes back to timeliness—the more evidence that exists on a particular research question, the less likely it is that the results of the HTA would be prone to variation. Tapani Piha developed the idea of harmonisation by telling delegates about forthcoming work to promote HSPA and HTA across Europe, including Article 15 of the cross border healthcare directive regarding co-operation and avoidance of duplication of effort. The work of EUnetHTA in developing a core HTA model and, more recently, in developing joint HTAs across countries, was highlighted, as were the three mechanisms the EU has at its disposal to aid co-operation: money, law, and networking.

Nicola Bedlington, of the European Patients Forum, spoke about patient empowerment and the increasing expectations on patients to manage their own health. Whilst noting that this required a new level of health literacy, she pointed out that having patients involved and listened to in healthcare can generate better outcomes. She noted the need for clearer methodology in involving patients, particularly within the HTA model, where the unmet needs of patients can be considered further by policy makers. She also conceded, however,  that patient expectations need to be managed in terms of what an HTA process is likely to provide them (clue: this may not always be that new treatment they were hoping for) to spare politicians from emotive arguments caused by HTA “no” decisions. E-health was also discussed, and Bedlington appreciated the potential of this, with the caveat that patients need only share what they choose. Examples of where e-health is already working within (Sweden) and outside (Australia) Europe show that online patient records are fast becoming a reality and big data in health could soon become routine.

Jennifer Hislop is a Young Gasteiner and a research associate at Newcastle University, England.

I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.