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The contribution of the National Health Service to gains in quality adjusted life expectancy: lessons from the past and implications for the future

The contribution of the National Health Service to gains in quality adjusted life expectancy: lessons from the past and implications for the future

This research project is being supported by as a three year British Academy postdoctoral fellowship.

Despite prodigious gains in the health of the population of England and Wales during the twentieth century there have been increasing accusations of inefficient and costly health delivery under the NHS. The aim of this project is to provide a substantiated estimate about the contribution of the NHS to the health and welfare of the population over the twentieth century. This will be achieved through the creation of a quantitative methodology that can value health gains attributable to healthcare. In the process of generating the most meticulous results to date about the performance of the NHS and its contribution to the improved health of the population the project will evaluate different approaches to healthcare delivery (in England and the United States over the twentieth century) in order to generate justified policy recommendations about the most efficacious future approach of the NHS.

Considerations about the contribution of health services to health gains will be made for England and the USA because they represent two relatively similar economies – in terms of development and broad health profiles – but have had contrasting healthcare delivery, funding and management systems and the largest margin in healthcare spending out of all OECD countries in the year 2000. The twentieth century will be considered by the project with a dichotomy between the periods 1900-1948 and 1948-2000. In this project health will be evaluated as mortality and morbidity (referred to as ‘Quality Adjusted Life Expectancy’ [QALE]). The appeal of considering health as a combination of the death rate and the prevalence of illness adjusted for the burden have been outlined in the literature and also highlighted by my PhD thesis.

This project builds upon the original methodology and conclusions of my thesis, which measured ‘Quality Adjusted Life Expectancy’ (QALE): mortality gains in conjunction with morbidity gains (prevalence of a disease adjusted for the ‘quality adjusted life year’ [QALY]), for twentieth century England and Wales. Gains in the QALE were valued, in monetary terms, and appended to GDP growth for the twentieth century. The results of this exercise highlight the need to consider health gains as more than just improvements in the death rate and also that health gains are very valuable.

Once the QALE gain results have been generated for the USA, they will be compared with my existing QALE gain estimates for England. Both QALE gains will be applied to a further methodology which will identify the amount of QALE gain generated by the health service in the USA and England. This is because not all improvements in health are a result of medical interventions. For example, the health benefits of preventative healthy lifestyles and national education initiatives (which were in their infancy at he close of the twentieth century, but are likely to become increasingly important in the twenty first century as healthcare costs escalate). This part of the project will identify the quality and drawbacks of different approaches to healthcare delivery (as identified by the results about QALE attributable to healthcare in England and the USA during different eras of the twentieth century) and in the process will provide conclusions about the potential of different approaches to healthcare delivery, funding and management, which will provide a crucial insight for the concluding policy suggestions of the project.

The project will provide valuable contributions to knowledge through answering the following central questions. The initial question (what has been the comparative value of the QALE gains in England and the USA during the twentieth century?) will enhance the existing USA mortality only estimates, for periods before 1970. Following on from this the project will answer: how much of these QALE gains are attributable to healthcare? And, what delivery (prevention, diagnosis or treatment focused), financing (closer to 15% of GDP as in the USA or 7% as in the UK in 2000) and management (public, private or some hybrid) approaches to healthcare yield the greatest QALE gain return? Currently only healthcare attributable to mortality estimates exist and these estimates tend not to consider long run historical time series and very few of these studies have contemplated mortality attributable to different stages of healthcare and none of these studies have adopted such a holistic concept of health (QALE) and healthcare (delivery, financing and management). The project results will also answer: what are the most efficacious approaches to healthcare? And, are these approaches being fully utilised by the NHS? The project will conclude with a robust answer to: what do all of these findings imply for future NHS policy?