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Reference: Brazier J. E. et al (2019 

This week’s paper of the week is brought to you by Professor Sir Muir Gray, 3V’s Founding Director.

Bottom line, chosen by Muir from the paper

This raises the issue of what is meant by “well-being.” A broad conception of well-being is how well an individual’s life is going on. Subjective well-being (SWB) has been described or categorised into 3 types: hedonism (well-being increases when an individual experiences more pleasure and/or less pain), flourishing theories (well-being increases when an individual fulfils their nature as a human being, or “flourishes”), and life evaluation or life satisfaction (well-being increases when an individual positively assesses his or her life).

The notion of SWB is often confused with capabilities, but this concept has a different genus. It can be attributed to Amartya Sen, who argued that society is interested with what you can do or be (ie, capabilities), and not just what you actually choose (or happen) to do or be (which he calls functioning).This addresses the fact that we may not choose to walk to the shops, but we value the ability to do so.

The development of online valuation methods has had a major impact on the field, and this is likely to continue. Nevertheless, we would voice a note of caution and recommend that more time be spent in allowing respondents time to deliberate on their answers because the numbers will have such an important application in informing the allocation of scarce resources.

Finally, there has been an ongoing argument on the role of patient values or experience-based values, and we expect this debate to continue. To date, this perspective has seen little take-up by decision makers and there are significant technical problems to obtaining representative and meaningful values that reflect just the health state. We anticipate that the use of experience-based values may play into an agenda to increase the patient voice, but the issue is a normative one of whose values should be used to inform resource allocation in a publicly funded system. Many decision makers are likely to continue to want to focus on health and maintain consistency with past decisions. As the decision of whether and when to adopt the 5-level EQ-5D by NICE shows, consistency with past decisions is key, and any new measure, change in whether the measure captures beyond health, or any method of valuation will be subject to far greater scrutiny than the original 3-level EQ-5D and its value sets.


Implications for value improvement

The big shift that has taken place has been the paradigm shift from focusing only on the quality of the inputs to a focus on outcomes but whose outcomes?

Good work has been done to develop objective measures of outcomes that can be used for comparative purposes, the Oxford Knee Score but this needs to be complemented by the measurement of outcomes that matter to patients.

The most respected is the EQ-5D but this paper points out that there are other dimensions that need to be covered to measure capabilities and SWB Subjective Well-being more accurately. However so few services are using even the EQ-5D that to call for a more comprehensive tool is not the central issue . We need to get more services indeed all services, particularly elective surgery services, to identify explicitly what is bothering the person called the patient most and to ascertain the outcome related to that problem. he technology is simple

The people we call patients need to be asked to think about and write down what is bothering them most before they come for the face to face consultation, using a simple prompt

• What is bothering you most?
• What do you hope the health service can do about what is bothering you most?
Then , after the intervention, asking

• Since you had our treatment is the problem that is bothering you most,

  • Better?
  • The same?
  • Worse?

We need to focus not only on outcomes of importance to the health and social care but also on outcomes that matter to the people called patients