This paper explores how medical practice ought to be conducted, in the face of scarcity, if our objective is to maximise the benefits of health. After explaining briefly what the cost-per-QALY criterion means, a series of ethical objections to it are considered one by one. The objectors fall into four groups: a. those who reject all collective priority-setting as unethical; b. those who accept the need for collective priority-setting, but believe it is contrary to medical ethics; c. those who accept (...) the need for collective priority-setting, and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it; d. those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. -/- The purpose of this discussion paper is to give each group a hard time! (shrink)

Many leading health economists hold misconceived ideas about central components of their work. In particular, they assume that their methods are in principle valueneutral. This belief is demonstrably false. Health economic investigations incorporate mainly unexpressed theories of health. Unless this fact is recognised health economics will shortly reach a conceptual and practical dead end. The way to avoid this dead end is to express implicit theories of health, and explicitly to base philosophically and economically justifiable policy proposals on them.

Incisively written, this new edition of a popular guide first published in 1996 slices through the rhetoric of health promotion. Its penetrating analysis quickly reveals health promotion’s conceptual roots, providing an enlightening map of their web of theory and practice. David Seedhouse proves that health promotion, a discipline intended to improve the health of a population, is prejudiced—every plan and every project stems first from human values—and argues that only by acknowledging this will a mature discipline emerge. To help speed (...) progress the author proposes a positive, practical theory of health promotion destined to inspire anyone who wishes to create better health. This new edition includes three new chapters on conventional health promotion, radical and foundational health promotion and mental health promotion, providing examples of the use of foundational health promotion. This new edition also adds five new teaching exercises, incorporates and updates the guide for teachers and lecturers and includes a new topical case study. This book is laced with entertaining dialogues and readers are encouraged to explore ten carefully presented exercises. Educational, accessible and intelligent, Health Promotion: Philosophy, Prejudice and Practice, 2nd Edition is a seminal work which heralds the beginning of the end of health promotion’s long adolescence. It is nothing less than essential reading for all practitioners and students of health promotion. (shrink)

I said at the beginning that some quantum leaps in our thinking would be required as we face up to the challenges and changes that health care delivery will and must undergo.It is not a matter of politics, it is a matter of pragmatism.It is a matter of reality and it's a matter of simply having to face up to what, may I say, has been glaringly obious for some time.I know that doctors come with a strong ethos in terms (...) of their commitment to their patient and that is as it should be, but governments are always going to be constrained by the amount of money that is available to spend in any one particular field of health service.Within the priorities that governments have, health versus education, versus welfare, versus debt, debates will continue to be had.One of the strengths of New Zealand's health services, with its contracting arrangements, is that it is able to respond flexibly to the priorities that the government sets for the health services it seeks to deliver to every person in New Zealand.I am very optimistic that over time this new model of funding of our New Zealand health services will see a fairer distribution of the health dollars available to meet the wide range of medical needs of New Zealanders.Health care delivery is changing rapidly around the world.If we are to keep up in the future we must be realistic now. The challenge is mine as Minister of Health. The challenge is yours as health professionals. The challenge is ours as a community. (shrink)

A family of instruments has been developed over the last twenty five years in order to measure the individual's subjective view of his health. The instruments vary in how broadly they define health. A wide range of critiques have challenged both the validity of these measures and their uses. This paper argues that disproportionate attention has been given to one form of health status measure—the so-called utility-based measures. The ensuing controversies have distracted from the substantial progress achieved in the application (...) of health status measures. This paper identifies the major areas of progress and argues that any serious critique needs to engage with this now sizeable body of applied knowledge. (shrink)

Recent years have witnessed a growing interest in the measurement of health status. One of the most well-known health status instruments is the Sickness Impact Profile (SIP). This paper examines the nature, development and testing of the SIP (and its UK equivalent the FLP). The practical merits of these instruments are explained, and some cautionary remarks are offered about their limitations.

This paper discusses the use of subjective health assessment in medical practice and social policy-making. The importance of recognising patients' perceptions of their health when attempting to improve patient-practitioner relationships and formulate effective health care policies is stressed. The paper describes some of the tensions that exist between objective and subjective assessments of health. It is argued that there is a need for a unifying theory to underpin the use of subjective health perceptions. Suggestions are made for the effective employment (...) of these indicators. (shrink)

The future clearly lies in restricting the introduction of new treatments into medical practice unless they are beneficial and an improvement over existing compounds, together with a stepwise re-evaluation of current therapies. The days of analogue development which give 10% or 15% improvement in toxicity over existing compounds are no longer acceptable, and resources should be preserved for real advances. These may require support in their development, particularly at the randomised controlled trial level, by government or research institutions in collaboration (...) with industry.Patients in general are now better informed by their physicians, nurse specialists and self-help groups, although few regions have gone as far as Oregon in information dissemination and involvement of patients in resource allocation decisions. We should take comfort from the fact that in spite of all the difficulty, new treatments continue to be developed, reflecting a commitment from the public, government and the private sector for continued progress. The way forward may be challenging, but the medical profession has to demonstrate leadership by countering the short-sightedness and over-regulation which has resulted from the recent economic recession. We should be seen to be acting with foresight in maintaining the quest for real improvement in the best interests of patients. Governments in turn have a responsibility to ensure they maintain independent bodies of professionals who have the qualities of flexibility, critical ability and vision to ensure continued development of high quality care. (shrink)