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Objectives: No EQ-5D-5L value sets are currently available in the Middle East to inform decision making in the region’s health care systems. This study tests the feasibility of eliciting EQ-5D-5L values from a general public sample in the United Arab Emirates (UAE) using the EuroQol Group’s standardised valuation protocol.Methods: Values were elicited in face-to-face computer-assisted personal interviews. Adult Emiratis were recruited in public places. Respondents completed 10 time trade-off (TTO) tasks and seven discrete choice experiment (DCE) tasks, followed by debriefing questions about their experience of completing the valuation tasks. Descriptive analyses were used to assess the face validity of the data. Results: Two-hundred respondents were interviewed in December 2013. The face validity of the data appears to be reasonably high. Mean TTO values ranged from 0.81 for the mildest health state (21111) to 0.19 for the worst health state in the EQ-5D-5L descriptive system (55555). Health states were rarely valued as being worse than dead (6.2% of all observations; 10.0% of all valuations of 55555). In a rationality check DCE task whereby a health state (55554) was compared to another that logically dominated it (55211), 99.5% of respondents chose the dominant option. The majority of respondents stated that their religious beliefs influenced their responses to the valuation tasks.Conclusions: Our results suggest that it is feasible to generate meaningful health state values in the UAE, though some adaptation of the methods may be required to improve their acceptability in the UAE (and other countries with predominantly Muslim populations).

In 2009, NICE issued supplementary advice to its Appraisal Committees to be taken into account when appraising life extending, ‘end of life’ treatments. The advice indicates that under certain circumstances it may be appropriate to recommend the use of such treatments even if their base case cost effectiveness estimates exceed the range normally considered acceptable. However, the consultation carried out by NICE revealed concerns that there is little evidence to support the premise that society is prepared to fund end of life treatments that would not meet the cost effectiveness criteria used for other treatments. The study described here seeks to address this gap in the evidence. A discrete choice experiment (DCE) was used to elicit the preferences of a sample of members of the general public in England and Wales over a range of priority setting scenarios. Each choice task involved asking respondents which of two hypothetical patients they thought should be treated, assuming the health service has enough funds to treat one but not both of them. The patients were described in terms of their life expectancy and quality of life without treatment, and the life expectancy and quality of life gains achievable from treating them. In addition, the survey included two ‘extension tasks’ designed to examine the extent to which respondents’ priority setting choices are influenced by information about how long the patients have known about their illness. The DCE was carried out using a web‐based survey. A total of 3,969 respondents successfully completed the survey, each completing 10 DCE tasks plus two extension tasks. The sample is representative of the general population in terms of age and gender, and covers a range of social grades. The conditional logit model was used for modelling. The best fitting model analysed main effects plus three interactions: (i) life expectancy without treatment against life expectancy gain; (ii) life expectancy without treatment against quality of life gain; and (iii) life expectancy gain against quality of life gain. Using the model results, utility scores were calculated for all of the 110 possible profiles (combinations of attribute levels) in the full factorial design, as well as the predicted probability of choosing each profile from the full set of profiles. The highest ranked profiles (those with the greatest probability of being chosen) were those that involved substantial life expectancy and quality of life gains from treatment. There is a clear positive relationship between the size of the QALY gains from treatment in a given profile and the predicted probability of that profile being chosen. By comparison, whilst there is little evidence to suggest that profiles involving shorter life expectancy without treatment are more likely to be chosen than those involving longer life expectancy without treatment – the observed patterns are noisy. Overall, the results indicate that choices about which patient to treat are influenced more by the sizes of the health gains achievable from treatment than by patients’ life expectancy or quality of life in absence of treatment. The extent to which patients are at their end of life does not appear to be the driving factor, although it should be noted that all of the scenarios in this study involve relatively poor prognoses (across all profiles, the patient who is ‘best off’ without treatment would still die within five years). Some respondents appear to support a QALY‐maximisation type objective throughout, whilst a small minority always seek to treat those who are worse off without treatment. The majority of respondents, however, seem to advocate a mixture of the two approaches. Overall, the results call into question whether a policy of giving higher priority to end of life treatments than to other types of treatments is supported by the public, particularly if the health gains offered by the treatments being ‘de‐prioritised’ are larger than those offered by the end of life treatments. The results also suggest that the focus on life extensions and absence of quality of life improvements in the current NICE end of life criteria may be consistent with public preferences. Results from the extension tasks show that including information about the amount of time patients have known about their prognosis has a clear impact on preferences. All other thing being equal, respondents are less likely to choose to treat a patient if they have known about their illness for two years than if they have only just found out about their illness. Further investigation of this factor is recommended.

Investment in medical research is vital to the continuing improvement of the UK's health and wealth. It is through research that we expand our understanding of disease and develop new treatments for patients. Medical research charities currently contribute over £1 billion annually to medical research in the UK, of which over £350 million is provided by Cancer Research UK. Many charities, including Cancer Research UK, receive no government funding for their research activity. Cancer Research UK is engaged in a programme of work in order to better understand the medical research funding environment and demonstrate the importance of sustained investment. A key part of that is the Office of Health Economics‟ (OHE) 2011 report “Exploring the interdependency between public and charitable medical research”. This study found that there are substantial benefits, both financial and qualitative, from the existence of a variety of funders and that reductions in the level of government financial support for medical research are likely to have broader negative effects. This contributed to other evidence which found that the activities and funding of the charity, public and private sectors respectively are complementary, i.e. mutually reinforcing, rather than duplicative or merely substituting for one another. “Exploring the interdependencies of research funders in the UK” by the Office of Health Economics (OHE) and SPRU: Science and Technology Policy Research at the University of Sussex, represents a continued effort to build the evidence base around the funding of medical research. This report uncovers the extent to which funders of cancer research are interdependent, nationally and internationally. Key figures show that two thirds of publications acknowledging external support have relied on multiple funders, while just under half benefited from overseas funding, and almost a fifth are also supported by industry. In addition the analysis shows that the general public would not want tax funding of cancer research to be reduced, but would not donate enough to charities to compensate for any such reduction.

Background: The UK Government is proposing to include “burden of illness” in its proposed scheme for the value‐based pricing (VBP) of branded medicines. The VBP consultation document suggests that medicines that tackle diseases associated with high levels of burden of illness will be rewarded more highly than those that do not. It includes a definition of burden of illness that incorporates consideration of severity (in terms of either length or quality of life) and unmet need (the degree to which treatments exist). However, there is a dearth of empirical evidence on societal preferences regarding this particular definition of unmet need.Objective: The aim of this exploratory study is to design and pilot an approach to eliciting public preferences regarding the prioritisation of health care resources according to unmet need and severity.Methodology: In face‐to‐face interviews, respondents answered 11 questions. Some of these involved the consideration of hypothetical priority setting scenarios; others involved consideration of pairs of statement about NHS priorities and required choosing the statement with which they most agreed. The various questions were designed to examine the extent to which respondents were willing to make trade‐offs between health gains, treating the severely ill, and addressing areas of unmet need.Results: Sixty members of the general public in southeast England were interviewed in May 2012. We find that maximising health gain is considered by most respondents to be more important than the competing objectives of giving priority to the severely ill and giving priority to treating conditions for which no alternative treatments exist. According to the interviewers, most of the respondents showed a good understanding of the survey tasks.Discussion and Conclusions: Some of our findings run counter to those of empirical studies elsewhere in the literature that examine social preferences regarding unmet need and severity. However, framing effects clearly are at play, since the level of support for an implied policy of giving priority according to unmet need varies greatly from question to question. A key finding is that people’s responses to stated preference questions appear to be influenced heavily by the ways in which the questions are framed.

Background: It is often assumed that the objective of health care is to maximise health using available resources. This is the principle underpinning NICE’s use of cost effectiveness analysis based on incremental cost per QALY gained. Yet research on local NHS decision making shows that cost per QALY is far from the only consideration. Similarly, many key national health policy initiatives appear to be driven primarily not by QALY gain, but by ‘process‐of‐care’ and other considerations. The apparent disjunction between the goals being pursued by different agencies within the health care system has potentially important implications for efficiency. Objective: While the criteria used by NICE are well understood, the principles underpinning policy evaluation by the Department of Health (DH) have not previously been subject to any systematic enquiry. Since 2008, the DH has been required to undertake and publish Impact Assessments (IAs) identifying the costs and benefits expected from all new policy implementation. The aim of this study is to identify the benefits considered by the DH as relevant to its decision making, and to highlight implications for decision making across the NHS. Methods: We analyse all IAs carried out by the DH in 2008 and 2009. The stated benefits of each policy were extracted and a combination of methods used to categorise these. Other DH documents were consulted for information on the means by which these benefits are valued. Results: 51 IAs were analysed, 8 of which mentioned QALY gains as a benefit. 18 benefits other than QALY gains were identified. Apart from improving health outcomes, commonly referred to types of benefit included: reducing costs, improving quality of care, and enhancing patient experience and empowerment. Many of the policies reviewed were implemented on the basis of benefits unrelated to health outcome. The methods being used to apply a monetary valuation to QALY gains (in IA cost‐benefit calculations) are not consistent across IAs or with NICE’s stated threshold range. Conclusions: The DH, local NHS commissioners of health care and NICE each appear to approach resource allocation decisions in different ways, based upon different considerations and underlying principles. Given that all these decisions affect the allocation of a fixed health care budget, there is a case for establishing a uniform framework for option appraisal and priority setting.

Background: In January 2009, the National Institute for Health and Clinical Excellence (NICE) issued supplementary advice to its Appraisal Committees to be taken into account when appraising life‐ extending ‘end of life’ treatments. This indicated that if certain criteria are met, it may be appropriate to recommend the use of end of life treatments that offer an extension to life even if their reference case incremental cost effectiveness ratios exceed the upper end of the range normally considered acceptable. However, the public consultation carried out by NICE revealed concerns that there is little evidence to support the premise that society is prepared to fund life‐ extending end of life treatments that would not meet the cost effectiveness criteria used for other treatments. Objective: The aim of this exploratory study is to design and pilot an approach to examining whether the policy of giving higher priority to life‐extending end of life treatments (as specified by NICE) than to other types of treatment is consistent with the preferences of members of the general public. Methods: The survey used five scenarios to address the research question posed, each of which involved asking respondents to choose which of two hypothetical patients they would prefer to treat, assuming that the health service has enough funds to treat one but not both of them. The various scenarios were designed so as to control for age‐ and time‐related preferences, and to examine the trade‐off between giving life‐extending and quality of life‐improving treatments to end of life patients. Follow‐up questions were used to elicit additional information about the reasons for respondents’ choices. The survey was administered using face‐to‐face interviews. Results: Interviews were completed by a convenience sample of 21 members of non‐academic staff and postgraduate students at the University of Sheffield. The majority of respondents chose to treat the patient who is closest to their expected death or whose disease progression has been most sudden. Very few respondents expressed indifference or unwillingness to choose between the two patients. Discussion: The most common driver of respondents’ choices was a concern about how much time patients have to ‘prepare for death’, which indicates, prima facie, support for NICE’s end of life policy. However, the ways in which information on patient age and the timing of treatment affected responses was not straightforward and in some cases contrary to the authors’ conjectured predictions. The results also suggest that improving quality of life is at least as, if not more, important than extending life in the end of life scenario.

Objective: The objective of this paper is to examine how well the QALY captures the health gains generated by cancer treatments, with particular focus on the methods for constructing QALYs preferred by NICE. Methods: Data were obtained using a keyword search of the MEDLINE database and a hand search of articles written by leading researchers in the subject area (with follow-up of the references in these articles). Key arguments were discussed and developed at the Office of Health Economics oncology workshop in September 2009. Results: Three key issues emerge. First, the EQ-5D, NICE’s preferred measure of health-related quality of life in adults, has been found to be relatively insensitive to changes in health status of cancer patients. Second, the time trade-off, NICE’s preferred technique for estimating the values of health states, involves making assumptions that are likely to be violated in end-of-life scenarios. Third, the practice of using valuations of members of the general population, as recommended by NICE, is problematic because such individuals typically display a misunderstanding of what it is really like for patients to live with cancer. Conclusions: Because of the way in which it is constructed, the QALY shows important limitations in terms of its ability to accurately capture the value of the health gains deemed important by cancer patients. The paper concludes by proposing a research agenda for addressing these limitations.