Discuss quality of life and the concept of positive health.

Quality of Life, Well-being and Positive Health

• The essential distinction — the standard of living is objective (income, housing, occupation, consumption), whereas the quality of life is subjective (satisfaction, meaning, well-being)
• The two do not move together beyond a certain point — rising income improves quality of life sharply while basic needs are unmet, and much less thereafter, which is why economic growth alone is an inadequate measure of development
• The level of living is a third term — the actual conditions in which people live, comprising health, food consumption, education, employment, housing, social security, clothing, recreation and human freedoms
• Why quality OF life matters in medicine — as mortality falls and chronic disease rises, people live longer with illness, so survival alone becomes an inadequate measure of success
• The question "does this treatment add life TO years as well as years TO life?" is what quality-of-life measurement exists to answer
• How IT IS measured — generic instruments such as the SF-36, EQ-5D and WHOQOL-BREF, which allow comparison across conditions; and disease-specific instruments, which are more sensitive to change within a condition but do not permit comparison between diseases
• The WHOQOL instrument covers four domains — physical, psychological, social relationships and environment
• The composite measures that incorporate quality of life — the QALY (quality-adjusted life year), in which a year of life is weighted by a utility value between 0 (death) and 1 (full health); and the DALY, its counterpart in burden-of-disease work
• QALYs are used in economic evaluation, to compare the value of interventions through the cost per QALY gained — which allows a hip replacement and a cancer drug to be compared on one scale
• The ethical difficulties must be acknowledged — QALY-based allocation systematically disadvantages the elderly (fewer remaining years) and the disabled (a lower starting utility), which raises genuine questions of justice that economics alone cannot settle
• Positive health is the concept of health as more than the absence of disease — "the perfect functioning of body and mind" with a reserve of capacity to meet stress
• It is best regarded as a direction rather than a destination: an ideal that is approached but not attained, and which is not directly measurable — and saying so is more honest than pretending it can be quantified
• Well-being is now measured in its own right by many governments, using life satisfaction, sense of purpose and affect, on the argument that what is measured is what gets attended to
• The broader lesson for the clinician — the patient’s own assessment of their health is a better predictor of mortality and future service use than many objective measures, so "how do you rate your health?" is a question worth asking
• Patient-reported outcome measures (PROMs) apply this in practice, and are increasingly used to evaluate services rather than merely to count procedures
• The conclusion that ties the chapter together — health is not the absence of disease, cannot be measured directly, is determined mostly outside the health service, is distributed inequitably, and is best improved by acting early and on populations — and every later chapter in the subject is an application of those five statements
• Standard of living is objective and quality of life subjective, and the two diverge once basic needs are met
• Economic growth alone is an inadequate measure of development, which is why composite indices were devised
• Ask how the patient rates their own health; self-rated health predicts mortality better than many objective measures
• QALYs disadvantage the elderly and disabled, which is an ethical objection that economics cannot settle
• Generic instruments allow comparison across conditions while disease-specific ones are more sensitive within one
• WHOQOL covers four domains — physical, psychological, social and environmental — which is worth naming
• Positive health is a direction, not a destination, and admitting it is unmeasurable is more honest than pretending otherwise
• What is measured is what gets attended to, which is the argument for measuring well-being nationally
• Patient-reported outcomes evaluate services, rather than merely counting the procedures performed
• Chronic disease makes survival an inadequate measure, since people now live many years with illness
• Cost per QALY compares unlike interventions, allowing a hip replacement and a cancer drug to be weighed together
• Health is determined mostly outside the health service, is distributed inequitably, and is best improved early and at population level