Covid 19 and QuALYs

At its core the problem with the NZ government’s Covid-19 strategy is that they addressed themselves to a task that they were confident of addressing successfully, rather than the task that actually needed to be addressed. They are following a course of action that minimises deaths from Covid-19 in the short term, rather than maximising the health of all New Zealanders in the long run.

There are two particular consequences from this government’s chosen course of action. In both cases you need to understand the stupidity of focussing on “deaths” as your metric. Everybody dies! It is not whether a person dies that matters; but when they die, and the quality of life they have until they die.

Around the world public health bodies use the concept of Quality Adjusted Life Years (QuALYs) to decide whether to fund a particular treatment. [Please note this concept is not used subsequently when assessing whether to treat a specific patient.] When thinking about hip replacements, the logic would be something like this. The average person who might receive a hip replacement would have 20 years of life after the operation and their quality of life might be increased from 75% to 100% of a reasonable expectation of a full and healthy life at that age. So each operation would generate 5 QuALYs. In the UK some years ago the threshold was around £30,000 per QuALY (my memory may be faulty and these numbers are indicative only). So provided the hip replacement operation could be provided for less than £150,000 then UK NHS would fund hip replacements. Once a treatment has been accepted it remains on the list of NHS provided treatments, unless new clinical evidence calls this into question. How do Qualys relate to Covid?

First, by cancelling elective surgeries and out-patient appointments and laying off large numbers of General Practitioners NZ PHS prepared for an avalanche of Covid cases. However, this was at the expense of the service that NHS NZ normally provides. Given the pressure that NZ PHS is normally under, it is inconceivable that this “missed” care can be caught up. Patients not treated will find that their quality of life will be lower than it otherwise would be, and some of them will die earlier than they otherwise would have done. We will not know the names of these deaths, and they will not be reported at a daily press conference, but we can be sure that they do exist. And, of course, all the non-fatal outcomes will have adverse effects on the QuALYs experienced by those patients.

Second, economic activity is being severely restricted. This will affect health outcomes in two ways. First, it will lower money available to NZ PHS. So they will not be able to fund the cost per QuALY they might otherwise have been able to fund. If NZ PHS funds treatments costing less than $50,000 per QuALY today, then after the economic devastation being wrought by the government’s current actions NZ PHS might only be able to fund treatments costing less than $30,000 per QuALY. Second prosperity is directly linked to health outcomes. You only need to compare life expectancy in Fiji (70 years) with that in New Zealand (82 years). And, of course, during those years of life a person living in Fiji does not receive the same level of health care that is delivered in New Zealand. This results in lost QuALYs, particularly later in life (for instance not receiving a hip replacement in Fiji which does happen in New Zealand). Such economic differences are further exaggerated in the event of natural disasters. Fiji is struggling to cope with the effects of Cyclone Harold last week in a way the New Zealand did not struggle with the after-effects of cyclone Gita – Fijians would willingly accept a one way system on one hill in two year’s time as the only lasting consequence!

In handling Covid-19 New Zealand needed a government that levelled with us. This is a crisis, and flattening the curve is essential. However, it is a balance and this government has not even attempted to find that balance. The government should have told us that deaths from Covid were going to be part of the optimal solution. The government should have told us keeping the economy going as much as possible was part of the optimal solution. To ask whether a business was “essential”, in deciding whether to allow a business to operate, was to ask the wrong question. We should not be asking; Is a business essential? We should be asking; Can a business be carried on safely? Since Wuhan came out of lockdown New Zealand has been the country with the harshest economic shut down in the world. This is a difficult balance to strike – certainly challenging the experts to understand whether their forecasts were “worst” case or “central” case requires an intelligence and determination that would be uncomfortable for all involved. A government that is strong on pathos is poorly placed to do carry out this task. To deliver the best possible outcome from the Covid pandemic, New Zealand needed a government with intelligence, determination and courage. New Zealand will be suffering the consequences of this governments Covid-19 decisions for lifetimes to come.