Themes Emerging from Country
and Related Presentations
Notes from session 1545 – 1730
Thursday 17 February 2011
Albert Weale
Transparency
• All systems have many actors involved in making
decisions that affect priorities, some are explicit and
some are background (eg who sets bridge safety
standards?).
• How are decisions made? Korea case of not being clear
how new drugs are recommended.
• Some decisions made through bargaining between
industry and those setting expenditure priorities.
• Can have transparency on process but not on appraisal,
as in German example.
• Transparency versus negotiation.
Accountability
• French experience of greater
accountability to parliament through tighter
monitoring.
• Complicated sets of actors, with different
decision making processes.
• Different sorts of accountability to different
actors, eg costs and benefits.
• We should not neglect non-decisions (and
who benefits from non-decisions).
Participation
• How are stakeholder representatives selected? Are there particular
groups (patients?) who are key stakeholders? France increasing
patient representation.
• Thailand allows stakeholders to propose balance of
preventive/curative, picking priorities from list.
• Role of professional associations in recommending members for
assessment committees, compare Korea. Also the self-governing
principle in the German SHI system.
• Who makes up the crucial institution? Professional public
servants/volunteers/others?
• Is there a difference between starting as policy planners with costeffectiveness and forming priorities through deliberative
participation?
• Note: our political science on the comparative functioning of different
methods of participation is weak.
• Citizens, patients, stakeholders, providers.
Clinical Effectiveness/Evidence
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Who generates the evidence?
How is evidence brought together?
Decision strategies.
Information comes in all the time.
Reassessing risks.
• How to handle statistical information.
World of risk or uncertainty?
Cost Effectiveness
• Value or vehicle?
• NICE legally required to look at this, also Korea
drugs assessment. Implications of such a legal
requirement?
• Use of threshold approach. Moving to valuebased pricing and efficiency frontier approach.
• Health analysis across diseases or not.
• High value/high intensity care is not necessarily
quality care.
• Cost effectiveness of displaced care.
Equity/Justice
• Different types of scheme for different people. Role of
HTA in helping to reduce disparities.
• Choice of prioritisation criteria.
• Broader context of social justice, as exemplified in fixed
budget systems.
• Open ended system.
• Due process aspects, and the time taken to do appraisal,
model of early benefit assessment.
• Inter-generational issues when care becomes important.
Sustainable solidarity: duty to keep the system viable for
the future.
• Note also the issue of discounting.
Solidarity
• China’s distinction of social pooling and
individual account.
• Cost-sharing is an issue in all systems.
Basis is important, eg cost-sharing
implications for high cost patients.
• Differential packages.
Autonomy
• Use of co-payment regimes to allow
greater autonomy? Moving down the tier.
• Using providers outside of ACOs, exit and
voice.
Social Values
• Economic and social. Economics as good
way of revealing social values: (process
modelling). But what is economic
analysis? Financial cost/opportunity as
alternative readings.
• Is the problem how to balance equity and
cost assessment? Or is it how to structure
prudently finance adequate health care?
Institutions and Levels of Decision
Making
• All these decisions take place in specific
institutions.
• Reconciling the macro and the micro.
• National and local – post-code rationing debate
in UK.
• ACOs seem to face same problems by and large
as national systems, but the ‘gaming’ issue is
distinct. Exit, voice and loyalty?
• EU and the right to cross-border care.
• Devolved decision making and its implication for
accountability. Back to the future.
Practical Reasoning
• Requirement for empirical evidence.
• Scoping the decision making process, in values and
empirical evidence.
• Attempts to systematise the decision making process
(Thailand).
• NICE ICER is a ‘rule and exemption’ approach.
• Unhelpful distinction of scientific and other.
• Scope of evidence needed for social care interventions.
• Looking at decisions made in other places – learning
from comparative evidence.
• Avoiding a mechanistic approach.
Defining Benefit
• Discussions about the value of innovation.
• Assessing community benefit from a range of
interventions – feeds into issues of evidence and
the difficulty of getting synoptic evidence.
• Value-based purchasing of drugs.
• Should not equate costly care with quality care.
• Health care services or priority setting for public
action.
Measurement/Operationalisation
• Data reduction is always involved.
• If we are interested in equity, how do we
know that we are achieving what we aim
for?
• Measuring community benefit, adding
marginal value.
Research Question
• Keep institutions in mind.
• What would policy makers find useful to
help them with their decisions?
• What would you like to know about other
systems?
• What are your key challenges?
• If there is sufficient convergence on value
matrix, is the question then HOW?