Investigating public preferences on ‘severity of health’ as a relevant condition for setting healthcare priorities

Abstract

This study examines the preferences of a sample of the UK general public over the allocation of healthcare resources. Preferences were elicited against scenarios where alternative patient groups are competing for limited resources. Respondents were asked to make a choice between either (i) groups described according to alternative descriptions for severity of health condition, or (ii) groups described according to a broader level of disadvantage (e.g. family income). The survey used a random-location quota sampling approach, and face-to-face interview techniques. Interviews were completed with 261 people in the Southampton area of England. Results showed that the majority or respondents wanted to divide resources equally between competing groups, giving at least equal preference to the more severely affected group, and the more disadvantaged group, regardless of a stated lower potential health gain in these groups compared to alternatives. In the severity of health question 60% indicated that a unit of health gain in a severely affected patient group was of greater social value to that same unit of health gain in a moderately affected patient group, all else equal. When described by level of disadvantage, 80% of respondents stated such a preference, which indicates that they attach a greater social value to a unit of health gain in a disadvantaged patient group, compared to a more advantaged group, all else equal. When given an option to ‘opt out’ of a difficult decision, and to ‘let others choose’, very few respondents (5%) took that option, suggesting that the most common stated preference of dividing resource equally between groups may be a true preference, rather than respondents avoiding difficult decisions. When interpreting the findings from the survey, results suggest that preferences reported to give priority to those more severely affected by their health, may also be a reflection of a broader preference to treat those groups classed as worse-off, in empirical studies. Results are discussed against the growing importance of the empirical ethics literature, and the growing needs of health policy makers to seek out an empirical basis upon which to consider the challenges of setting priorities in healthcare.

Introduction

When setting health policy or planning for the delivery of health care, at a national or devolved decision-making level, there is a need to set priorities when allocating resources. Those involved in making such difficult priority-setting decisions have increasingly explored the notions of fairness and equity to inform the decision making process (e.g. PBAC (Australian Pharmaceutical Benefits Advisory Committee), 2004, Rawlins and Culyer, 2004, NICE(UK National Institute for Health and Clinical Excellence), 2005). Yet there remains considerable ambiguity, and a lack of operational guidance, on what might be meant by fairness and equity (Newdick, 2005). Definitions against these distributive ideals are generally given at an abstract theoretical level (e.g. vertical and horizontal equity), or they are commonly confused with aspirational notions of equality (e.g. equality of health, equality of access according to need) (Sassi et al., 2001, Sen, 2002, Hauck et al., 2003).

One source of guidance, when setting priorities, is the growing literature on the incorporation of distributive preferences when making resource allocation decisions (e.g. whether to fund technology X for patient group Y), especially the empirical literature that examines a range of potential social considerations. This literature includes empirical research to assess, and often quantify, the importance of factors such as patient characteristics, characteristics of health care interventions, and broader societal considerations (e.g. reducing inequalities), when making resource allocation decisions. This type of research has been referred to as ‘empirical ethics’ (Culyer, 2001, Richardson, 2002, Richardson and McKie, 2005), and there have been a number of informative reviews (Sassi et al., 2001, Schwappach, 2002, Dolan et al., 2005, Green, 2007).

In the empirical ethics literature, studies are mostly considering one particular concern for fairness at a time, and contrasting it with prominent efficiency objectives related to cost-effectiveness, and the maximisation of quality-adjusted life-years (QALYs). One such concern for fairness is the consideration of the severity of a health condition (pre-treatment health state). The empirical studies informing the severity of health approach (e.g. Nord, 1993a, Nord, 1993b, Nord et al., 1995, Dolan, 1998, Ubel, 1999, Cookson and Dolan, 1999, Oddsson, 2003, Gyrd-Hansen, 2004), have been widely cited in the health care literature to support a hypothesis that health state values (e.g. QALYs) often fail to capture and represent the nature of public preferences. But, more specifically, they have been used to support a ‘severity hypothesis’ where the basic premise is that the social value of a health improvement (of a given size) is greater the greater the severity of the initial health condition (Nord, 2005).

The severity hypothesis may be a fair reflection of public preferences, and a reasonable approach for setting priorities. But current empirical research in this area, as with almost all notions of distributive preference, comprises studies that are mostly simple experimental studies, often without clear policy implications, and further research is required against a severity of health criterion in the context of a broader range of distributive preferences.

In this paper, as well as considering the empirical support for the use of severity of health as a priority-setting criterion, a further aim is to explore the broader interpretation of the empirical evidence reporting a stated preference to treat those groups regarded as more severely affected by their health status. This latter aim is informed by a recent systematic review of the literature around fairness and equity considerations, in health care priority-setting dilemmas (Green, 2007), covering over 100 empirical studies. This review, in a very diverse and difficult to interpret literature, noted that in many studies respondents favoured the worst-off groups (e.g. those with worse health condition, poorer prognosis, those subject to greater inequality), from a set of groups competing for the same scarce resources. This observation was visible across a range of different study settings (contexts), and in studies employing a range of methodological approaches, with those groups that would be regarded as ‘worst-off’ being given equal or priority-preferences, regardless of their more limited capacity to benefit (e.g. lower health gains). This notion of ‘worse-offness’ has been referred to in the literature (Nord, 2005), but has not been considered directly, in the context of preferences around treatment of those more severely affected by their health. Therefore, one hypothesis explored here is that a preference registered for the more severe of two competing groups in an allocation problem, reflects a preference to treat ‘the worst-off group’. With such a preference reflecting not only a social value to treat severely affected groups (in specific studies), but a broader and general preference for ‘fairness’ in the treatment of worse-off groups. The motivation here is not to disprove the specific hypothesis of a preference for severity in such instances, but to further investigate the meaning of the preferences reported to support a severity of health argument.