Any health service needs to ration the care it provides somehow - there are not enough resources to pay for all and every course of treatment that may be of benefit. The UK has, in principle, a highly institutionalised way of rationing care through the National Institute for Health and Clinical Excellence. The basic idea is that NICE studies the medical evidence and makes an informed cost-benefit judgement on the desirability of a particular treatment. If the social costs look bigger than the social benefits then they provide guidelines to the National Health Service that the treatment should be provided. The advantage of this system is that it promotes systematic, objective, universal judgements.
But, this week we saw some of the problems with such a system. NICE announced that IVF treatment should now be available to women aged up to 42, rather than the current 39. It was decision that prompted a lot of discussion. Most discussion seemed to revolve around two distinct issues.
Part of the discussion revolved around a 'Lucas critique like' criticism of the decision. At the moment there are presumably lots of women aged 40 to 42 who could have healthy babies through IVF but are not given the opportunity. Now they should be - which looks like a good thing. The concern, however, is that the change of policy will incentivize women in their late 30's to delay having children - and given that delaying child birth leads to a higher probability of complications, this looks like a bad thing. We get, therefore, a classic policy conundrum - will a change in policy, change behaviour? Most doctors I heard on the radio were of the opinion that behaviour would not change and hence the policy is a good thing. Some doctors, however, we arguing that behaviour would change, and I have some sympathy for this latter view.
Game theory and behavioural economics teaches us that people are highly responsive to both incentives and framing. In this instance both combine. Women are incentivized to have children later in life (or, at least, are not incentivized to have them early in life). Moreover, the NICE decision makes having children later in life 'seem safer', or 'seem easier'. As this decision feeds through to society - as people get to know someone who knows someone who had IVF when she was 41 - its hard for me to believe this will not change behaviour. At the margin, women will delay childbirth. Whether this is a good thing or not is not for me to judge. But, it does highlight a potentially problem with NICE. It is so big and important that its judgements can change behaviour and perceptions. NICE currently ignores this, but it shouldn't. If the IVF policy does mean some women delay childbirth then it has social benefits and social costs that NICE will have ignored and so we may get the wrong guidlines.
The second issue of discussion was whether the guidelines mean anything. Cash-strapped NHS trusts already refuse IVF to women in their late 30's and so its not clear whether the guidelines will be followed through. This raises a fundamental question about the role of NICE. If its role is to advise on treatments that are cost effective then why is that advice being ignored? The simple answer would be that not enough money is being spent on health care. A more complicated answer would be that the way NICE makes judgements mean it is not flexible enough to ever work.
To explain, suppose that NICE says yes to any treatment that provides an extra QALY (quality adjusted life year) for £30,000 or less. For example, advances in IVF mean that its made available to women up to age 42 because it fits the criteria. Problems come when there are so many advances, and so many patients, that the NHS budget can no longer cope with providing every treatment that costs £30,000 or less. Fine, we can raise the bar to, say, £35,000. This, however, will naturally, only be applied to new treatments. It would be deemed unethical to stop funding treatments that had previously been funded. This inability to change guidance on existing treatments means that NICE can never satisfy its remit of rationing health care. (NICE does change guidance on some existing treatments, but only if new information changes the estimated cost-benefit analysis.) To ration health care most effectively would require constantly changing the cost society is willing to pay for a QALY. That is unlikely to ever be deemed acceptable. Over time we could thus see an erosion of NICE's importance as guidelines increasingly become ignored. That puts doctors and nurses back in the driving seat in terms of rationing care.