Equity - some theory and its policy implications

This essay seeks to characterise the essential features of an equitable health care system in terms of the classical Aristotelian concepts of horizontal and vertical equity, the common (but ill-defined) language of “need” and the economic notion of cost-effectiveness as a prelude to identifying some of the more important issues of value that policy-makers will have to decide for themselves; the characteristics of health (and what determines it) that can cause policy to be ineffective (or have undesired consequences); the information base that is required to support a policy directed at securing greater equity, and the kinds of research (theoretical and empirical) that are needed to underpin such a policy

Economics and ethics in health care

This editorial provides a review of the current ways in which health economics is impacting on policy and reviews some of the key ethical and value-judgmental issues that commonly arise in and as a result of the work of economists. It also briefly highlights the contributions of the authors of this special issue of the journal, all of which illustrate how economists have approached ethical issues in health service policy (both in its financing and its delivery), and some of which explore the major methodological matters that arise and go on to discuss their potential as sources of conflict or harmony with other approaches to the same question

National Institute for Clinical Excellence and its value judgments

The National Institute for Clinical Excellence (NICE) offers health professionals in England and Wales advice on providing NHS patients with the highest attainable standards of care. NICE gives guidance on individual health technologies, the management of specific conditions, and the safety and efficacy of interventional diagnostic and therapeutic procedures. Guidance is based on the best available evidence. The evidence may not, however, be very good and is rarely complete. Those responsible for formulating the NICE’s advice therefore have to make judgments both about what is good and bad in the available science (scientific value judgments) and about what is good for society (social value judgments). In this article we focus on the scientific and social judgments forming the crux of the institute’s assessment of cost effectiveness. Scientific value judgments and those relating to clinical effectiveness are considered elsewhere

Does cost-effectiveness analysis discriminate against patients with short life expectancy? : Matters of logic and matters of context

The aim of this paper is to explore the claim of ageism made against the National Institute for Health & Clinical Excellence and like organisations, and to identify circumstances under which ageist discrimination might arise. We adopt a broad definition of ageism as representing any discrimination against individuals or groups of individuals solely on the basis that they have shorter life expectancy than others. A simple model of NICE‟s decision making process is developed which demonstrates that NICE‟s recommendations do not inherently discriminate on the basis of life expectancy per se but that scope for discrimination may arise in the case of specific technologies having identifiable characteristics. Such discrimination may favour patients with either longer or shorter life expectancy. It is shown that NICE‟s policies, procedures and the context in which NICE makes its decisions not only reduce the scope for discriminatory recommendations but also – in the case of “end of life” treatments – increase the likelihood that NICE‟s recommendations favour those with shorter, rather than longer, life expectancy

'NICE's use of cost-effectiveness as an exemplar of a deliberative process'

This paper seeks to test 12 conjectures about the predicted use of deliberative processes by applying them to the technology assessment procedures used by the National Institute for Health and Clinical Excellence (NICE) in England and Wales. A deliberative process is one that elicits and combines evidence of different kinds and from different sources in order to develop guidance – in the present case, guidance for a health care system. A deliberative process entails the integration of three kinds of evidence: scientific context-free evidence about the general clinical potential of a technology, scientific context-sensitive evidence about particular evidence in realistic scenarios, and colloquial evidence to fit context-free scientific evidence into a context and to supply the best evidence short of scientific evidence to fill in any relevant gaps. It is shown that NICE's appraisals procedures and, in particular, its approach to cost effectiveness, entail both the weighing of each of these types of evidence and can be seen as rational responses to the 12 conjectures