Putting a price on health

A key objective of the Labour government’s health strategy is the
provision of patient choice. A separate but equally significant
objective is that of achieving cost-effectiveness: that is, of
getting value for money from spending on health and social care
services.

Between these two goals there is potential for considerable
conflict. Increasingly, the Department of Health is looking to
“evidence-based” research to provide support in determining what
policies and practices should prevail. This approach brings its own
problems as can be seen from one of the DoH’s own research studies.

The DoH is sponsoring a series of cost-effectiveness studies
co-ordinated by the University of York’s social work research and
development unit. In its second briefing paper it presents the
outline of a study into the costs and outcomes of different
interventions for sexually abused children.¹

A full account of the study has yet to be published, but details
are provided in the briefing paper. A group of sexually abused
girls were “randomly allocated to either individual or group
therapy”. The outcomes of the therapeutic interventions were
measured and it was found that both groups improved significantly
over time in terms of “psychiatric psychopathology and
functioning”.

However, the cost of individual therapy was calculated as being on
average £1,246 more expensive per person than that for group
therapy. The study concludes that, in cost terms, group therapy is
the more effective option – the only caveat being that there may be
logistical problems in setting up groups which can cause delays in
starting therapy for children who may have pressing treatment
needs.

The most logical outcome of this study is that the health service,
despite its commitment to choice, will not in future provide
individual therapy for sexually abused children. A decision along
these lines would force those requiring such a service to seek it
outside the statutory framework of provision. After all, if the DoH
is commissioning this type of research, why not act upon its
findings?

Of course, to do so would be totally unacceptable. And, in fact,
most studies into the sexual abuse of children have pointed to the
considerable shortage of any type of therapeutic
facilities.²

Another key finding of studies of sexually abused children (and
their carers), is that there is a range of responses to being
abused and that each child has their own particular needs that must
be addressed to ensure the best outcomes.³

This study indicates the need for the provision of more accessible
services offering greater flexibility and based on the expressed
wishes of the children themselves, which is in direct contrast to
the one-size-fits-all solution offered by the DoH’s
cost-effectiveness study.

But which studies are likely to have the most influence? The fact
that the cost-benefit analysis considered here has been sponsored
by the DoH ensures that it will be given serious consideration when
policy is being developed, and there is no guarantee that it will
be counterbalanced with independent research. The fact that this
study is concerned with evaluating the effectiveness of two types
of treatment to which subjects are randomly allocated gives it an
aura of being scientific and of carrying greater weight than other
studies not conducted in this way. Unfortunately, the synopsis of
this study suggests there are some major pitfalls.

The first of these is an ethical one. The fact that the sexually
abused girls were randomly allocated to either individual or group
therapy is of concern in itself. How this was done? Presumably,
they were not given a choice. At least one could be thankful that,
in the pursuit of scientific exactitude, a control group was not
left untreated.

A second issue relates to the evaluation of the outcomes that, as
has been noted, are said to have been positive ones. It is not
clear whether these judgements include the views of the children or
their carers. If, as I suspect, they do not, this raises even more
concerns about the issue of choice and who decides what is best for
whom.

It is clear that the parameters a piece of research sets for itself
and the way in which it is conducted have a major influence on the
findings and conclusions. Research that confines itself to
collecting data from the professionals and from documentation in
order to evaluate the outcomes of a project misses out on the key
participants in the process – the children and their carers – who
are best able to comment on whether the therapy has worked for
them.

Similarly, the focus on cost to determine what form of therapy to
apply to children who have been sexually abused seems insensitive
and, given what we know about the variation and complexity of their
reactions in these situations, misguided.

Although cost-benefit research can undoubtedly help in deciding
between the cheapest equally effective way to mend a broken finger,
it does not work as well with helping to “heal” sexually abused
children. If the government is truly committed to choice in health
care provision, then this seems to be an area where there should be
no question about providing it – almost regardless of cost.

On the other hand , if we are really forced to consider the costs
of providing treatment for sexually abused children and their
families, we must take into account research showing the
longer-term consequences of being sexually abused. Apart from the
human cost to every individual who has been abused, we could be
more hard-headed about calculating the financial cost associated
with the over-representation of women who have been sexually abused
in the psychiatric hospital population.⁴

In the light of this knowledge, penny-pinching on the provision of
therapeutic services for sexually abused children seems to be a
short-sighted and potentially expensive policy. 

Brian Corby is professor of social work studies,
University of Central Lancashire.

References


¹ Department of Health,
Costs and Outcomes of Different Interventions for Sexually
Abused Children in Costs and Effectiveness of Services for Children
in Need, Briefing Paper 2, 2003

⁴ C Wurr, I Partridge, “The Prevalence of a History of
Childhood Sexual Abuse in an Acute Adult Inpatient Population”,
Child Abuse & Neglect 20, 867-72