Valuing health directly

BMJ 2009; 339 doi: (Published 22 July 2009) Cite this as: BMJ 2009;339:b2577
  1. Paul Dolan, professor of economics,
  2. Henry Lee, clinical research fellow,
  3. Dominic King, clinical research fellow,
  4. Robert Metcalfe, PhD economics student
  1. 1Imperial College Business School, London SW7 2AZ
  1. Correspondence to: P Dolan paul.dolan{at}

    Decisions about which conditions and treatments to prioritise are never easy. Paul Dolan and colleagues argue that they should be based on people’s experiences rather than on what people think they might feel

    Valuing the relative benefits of different treatments helps us to allocate scarce healthcare resources to where they do the most good. The National Institute for Health and Clinical Excellence (NICE) advises on the cost effectiveness of treatments and recommends that health benefits should be valued in terms of gains in quality adjusted life years (QALYs). This approach assigns a value between 0 (for death) and 1 (for full health) to each health state and then multiplies that value by how long the state lasts. It makes good sense to value health benefits by accounting for duration in this way.

    We do, however, have serious concerns about NICE’s recommendations for the “quality adjustment” part of the QALY. NICE suggests asking members of the general public to think about how many years of life they would be willing to trade to avoid different states of health. The trouble is that these hypothetical preferences often bear little relation to the real experiences of those in the health states. This article offers an alternative means of valuation that could help direct resources to treatments in proportion to the real suffering they alleviate.

    Valuing health the NICE way

    There are three questions in valuing the Q in the QALY: what is to be valued; how is it to be valued; and who is to value it? “What” refers to the dimensions of quality of life under consideration. To compare a wide range of conditions, NICE recommends using a generic measure and it prefers the EQ-5D, which describes health in terms of three levels of severity for each of five dimensions (mobility, self care, usual activities, pain or …

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