COVID-19 and QALYs

We will have to wait a long time for a complete cost benefit analysis of lockdown in the UK, for the ‘Defeat of the virus’ remains uncertain and the bills will roll in for a long time yet.

Nonetheless, one simplistic calculation can be done.

COVID-19, and the response to it, including three lockdowns have increased the UK budget deficit by almost £400 billion. A concurrent 9.9% fall in GDP has undermined the tax base. How many lives have been saved by the actions taken is contentious, but let’s take Professor Ferguson’s original estimate of around 500,000 deaths with ‘Do nothing’ and then subtract the 125,000 COVID-19 deaths to date. That suggests 375,000 lives saved at £1.07 million each.

These figures are open to considerable criticisms, outlined below. Nonetheless, they have some official stamp and so provide a starting point. Moreover, they give lockdown the benefit of the doubt – I do not hear assertions that it has saved more than 375000 UK lives, nor that the Government deficit will rapidly shrink.

The estimated £1.07 million per life saved can be tested against NICE’s standard criterion that a new treatment is potentially fundable by the NHS if it costs less than £30,000 per ‘Quality Adjusted Life Year’ (QALY). For lockdown measures to meet NICE’s criterion they therefore need to be buying around 35 QALYs per ‘saved’ patient. Life expectancy in the United Kingdom is c. 79 years for men and 83 for women, with the last few years not counting as full QALYs owing to frequent ill health. So, to gain 35 QALYs per saved patient we’d need to be preventing the deaths of folk in their 40s.

In reality few people in their top 40s die of COVID and the median age of a COVID-19 death is 83 years. Life expectancy at 83 is around 8 years, and will be less in terms of QALYs. What is more, care home residents make up a considerable fraction (c. 33%) of all UK COVID-19 deaths and, on entry to a nursing home, one has a median life expectancy of only 462 days. In Scotland around 30% of COVID deaths were among patients with recent hospitalisation, implying (given that routine admissions have been restricted) that many had underlying disease, reducing life expectancy. Taking such groups into account it seems unlikely that more than 5 QALYS are being ‘saved’ per survivor and that the cost per QALY (c. £200,000) is around seven times NICE’s normal maximum.

Several criticisms will be raised to these calculations. First it will be objected that there are many approximations and simplifications. That is true. However, none is loaded to exaggerate the cost per QALY and several are biased to underestimate it, not least that the deficit and debt are still expanding. It will be objected that no account is paid to Long COVID-19. That is true, but that is balanced by also omitting the costs of mental health damage engendered by lockdowns and propaganda designed to engender fear.

Next, and with more justification, it will be asserted that ‘Something had to be done’. One can’t decently shrug at the prospect of 500,000 deaths’. Even Sweden, with a more measured response accrued a deficit of Kr402bn in 2020 (£34 bn, or around £341 per citizen compared with £588 in the UK). Their cost per QALY must be considerable too. The response here not the nothing should have been done but that the wrong things were done. Long-made pandemic plans were abandoned and the alternative of focused protection was summarily dismissed. The considerable sums spent would have been better spent protecting the most vulnerable whilst allowing the rest of the economy to function as normally as possible, reducing the need for vast spending on furlough and business support.

This leads to the and biggest criticism: namely that there is no proper evidence that 375,000 lives have been ‘saved’ by lockdown. The number comes from simple subtraction of actual deaths from Prof Ferguson’s disputed prediction. The death trajectory per 100000 population in Sweden, which did not lock down, has been no worse than in countries, including the UK, that have locked down. Florida, with a larger elderly population and no lockdown since September has not had a higher death rate than California, with far greater restrictions. These exemplars, and wider lack of correlation between lockdown stringency and COVID-19 death rates call its efficacy into question, except maybe as an early (and very expensive) response to a small, localised, outbreak, as in Melbourne. Moreover, there is little clear reason why generalised community lockdown should be efficacious once severe and fatal infection is substantially care-home and hospital associated.

If this last criticism is accepted, it follows that the estimated cost of £200,000 per QALY is far below the real figure.