Portfolio Careers 101: What’s so great about health economics? Part 1

Part 1 Personal Motivation: 3 Reasons

The World Turned Upside Down, an iconic sculpture within the LSE campus, that challenges our perceived notions of how the world looks, not just through maps and the graphical misappropriation of geography, but also our geopolitical self perception https://en.wikipedia.org/wiki/The_World_Turned_Upside_Down_(sculpture)

I had spent two years as a clinical chair of a deprived CCG, pondering during my quiet moments why it was so difficult to effect change? Were we as CCGs capable enough, was funding sufficient, did we have the right people? Did we have the right level of political support?

It is the last point I wanted to explore, the politics and what I perceived as a key missing factor.

Some things about the job that nobody prepared me for was the ‘level’ of political involvement (or just plain meddling), with both small ‘p’ politics with GP practices jostling for influence and big ‘P’ politics with elected counsellors & members of Parliament and other influential entities.

These thoughts ultimately led me towards health economics as a discipline.

Three ideas were swirling in my mind. Firstly, economics, the terms, the language and outsized influence on peoples’ thinking caught me by surprise. In the medical world, any clinician worth their salt implicitly understands the hierarchy of evidence. It is logical, immutable, clear. Somehow economics in its quasi-scientific vernacular of cost-effectiveness, or cost-efficiency or some other composite term that linked money and productivity, irritatingly always seem to trump ‘evidence based medicine‘.

This was particularly the case in a mixed audience which was both disconcerting and in some sense, funny. Occasionally, in management land, ‘important’ meetings were held involved managers, doctors, finance leads and the odd expert Economist. Inevitably, the economist would peer down his specs and opine with conviction on ‘sunken costs’, ‘time horizons’ or ‘healthcare elasticity’. Like deer, the non-economists (ie pleb medic me) would flash startled looks at one other….followed by ‘Churchill dog’ nods of intelligent approval, …followed by rapid fire WhatsApp notes asking what on earth was just said!

It’s not fun, feeling bamboozled. Patients must get this all the time from doctors, and it isn’t funny then either. I have to hold my hands up and chuckle at my own ignorance.

So, my first point is about understanding the language and what sits behind these seemingly impenetrable terms. Regardless of its composite nature, economics is an important discipline and way of thinking that is highly influential, if you want to stand a chance of influencing certain groups of people.

Ironically, most economists will tell you that most economic models don’t work but sometimes they can be useful!

Secondly, many technical arguments about matters important to healthcare and inequalities revolve around resource allocation & equity. Consider the Carr-Hill formula, weighted captation budgets, and their effect on the distribution of wealth across England. Prof. Marmot is hot on this, and rightly so! Having studied advanced health economics I can honestly say that many of these formula based on assumed factors such as instrumental variables (IVs). Essentially, a clever name for an assumed number.

Another oft raised dog-whistle is ‘moral hazard’, where it is assumed that people will overuse healthcare if it’s free, to maximise their utility and ‘unfairly’ squeeze every possible drop out of the system. If find this type of argument limited. It is only one side of the argument and does not take into account unmet need.

These arguments are anchoring points for important philosophical standpoints within society.  If you believe, for example, that swathes of the population are a bunch of spongers, you might pitch up on telly to cap welfare benefits, or limit access to health (think Trump and swingeing cuts to the affordable care act!). You might conveniently ignore the fact, that huge numbers of claimants live under the poverty line and will inevitably suffer catastrophic financial losses, as defined by the WHO. This, in my opinion, is effectively weaponising economic arguments for austerity, or conversely, making a perfectly decent prosocial counterclaim !

I go back to the point about language. What is important is having a deeper understanding, to get under the skin of these complex arguments, to both recognise its limitations, challenge and rectify matters that have a profound effect on the people we look after.

Thirdly, I was struck by a slide put up by Professor Chris Whitty at the inaugural medical school lecture in Canterbury, serenely painting a picture of rising healthcare standards across multiple disease areas. And yes, he is serene ! Health can only be responsible for a fraction of that improvement and that over time, cumulative benefits arise from multidisciplinary action. Engineering, the law, public health and many disciplines tessellate and interact at the edges to produce life extending and enhancing innovation.

Within medicine, a sort of conceit exists where, deep down, we posses a firm and unstable belief we are the centre of the universe and the fountain of everything good!

The reality is that being at the edge of medicine, where the Venn diagram of the natural sciences, the humanities and the arts intersect, is where all good stuff happens! At least that’s how it feels in my mind.  At that moment, I was convinced that I needed to do health economics.