Speaker 1: Hello, my name is Dr Hart Pinto and today we're going to be talking about medical ethics and the topic for today will be resource allocation, quality adjusted life years and the needs based model. So what is a quality? It is used as a concept of resource allocation. A quality adjusted life year is a measure of the value of health outcomes. So a year of life in perfect health is given a value of one and a year of unhealthy life is given a value of less than one, which may be 0.5, 0.3 etc. A healthcare system is therefore one which maximises quality adjusted life years and provides the most benefit for patients. So what about the cost effectiveness of quality adjusted life years? It's the utilitarian stance of maximising healthcare with the resources that are available. The most efficient healthcare system that exists is one where the cost per quality adjusted life year is low. Therefore we can maximise the number of quality adjusted life years per the pound or per the dollar. Okay so why should we use qualities? It will provide the maximum benefit for public with the finances that are made available. Therefore it's maximising the healthcare budget. Not only does it promote health but it also promotes the quality and quantity of it and how it influences patients' lives. But what are the negatives of quality adjusted life years? It discriminates against those with expensive healthcare problems. Let's look at some examples. A 60 year old patient with a major burn may require a prolonged stay in intensive care and repeated surgeries. In these patients the total cost of care may enter the hundreds of thousands and the patient may only live for another 10 years for example. Therefore the cost per additional year of health that he has gained is very high. In real terms that can mean that there's little benefit for society as a whole but it provides the maximum benefit for the individual in need and that's the important point. With the same amount of financial resources we can provide smoking cessation advice to tens of thousands of patients. That provides maximum benefit for society and the cost of the quality is

Speaker 2: low. Point two. It's an unjust method of service allocation. Two patients for example requiring

Speaker 1: the same treatment for a community acquired pneumonia. If we look at patient A they're fit and well and patient B has other comorbidities such as COPD congestive cardiac failure is

Speaker 2: scheming heart disease. If we use qualities for our resource allocation we would favour the treatment of patient A. But if we consider our first principles principle of justice

Speaker 1: states that both patients should have equal access to treatment. Is it fair for the patient who's got other medical conditions to not receive the appropriate treatment just because the other person will have a higher value of healthy years gained. Okay well if we're discriminating against patients who've got lots of comorbidities the elderly population are more likely to have these conditions. And when they receive treatment they're not going to gain 100 percent healthy life year. Their value of their life gained will be less than one. And so should they not have received treatment as well. In these circumstances we see that qualities favour those people who are younger and healthier. Qualities themselves don't specifically discriminate against age. You may have a 10 year old as well who has a condition that would significantly shorten their life expectancy. In these circumstances this young child would have the same discrimination as those patients who are elderly with multiple comorbidities as they cannot gain 100 percent healthy life even after their treatment. Let's put it another way. A 70 year old marathon runner with no medical concerns whatsoever may go on to live for another 10 or 20 years. In this patient he would have a greater potential for quality of life years gained. So is it just to provide treatment for this patient as it provides maximum societal benefit compared to treating a young child who has many medical comorbidities who may not live very long. Another way to look at it in contrast to qualities would be should we be giving preference to young people as elderly have already lived their life. Is that the right question to look at. Probably not. The second method of resource allocation is something called the needs based model. In this case it's based upon the concept that resources should be allocated to those patients who are most in need i.e. it prioritises the most sick. So that patient that we've discussed with the significant burn injury who is elderly he should justify having the treatment. And also that young child that we discussed who had a significant medical condition that was shortening his life. We should still treat him because he's in need. In reality rational citizens would wish for those who are worst off in society to have the maximal well-being. Whilst

Speaker 2: in principle this is a great idea we don't have infinite resources. And it doesn't always

Speaker 1: provide for society as a whole. For example should we spend all our budget on treating one single burn patient or could we treat a thousand patients with premalignant skin lesions. We know that using the needs based model whilst it's more generally accepted by the public provides a less efficient allocation of health care resources. And it provides increased costs to health care. So if we enter a system where only patients who are most in need are being treated we will only get patients who access health care when a life-threatening illness occurs. This can be due to neglect of a chronic disease for example angina which then becomes a myocardial infarction which potentially could have been prevented had we allocated resources to the management of those less in need who have chronic disease. So in a way the needs model isn't perfect either. Okay let's summarise what we've reviewed. So QALYs or quality adjusted life years are a method of maximising efficiency of the resource allocation. It essentially gives us the most bang for our buck and it's a utilitarian concept. It provides resource allocation which is best for society but not necessarily for the individual. And because it's looking at healthy life years gained it can discriminate against elderly patients and those who require the most help. The alternative model, the needs model, provides patients most in need with the treatment that they require. It is a less efficient method of resource allocation and you get less bang for your buck. And there's also associated reduction in resource allocation to those

Speaker 2: with chronic disease. Thank you for listening to this lecture. If you have any questions or

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