Abstracts Meeting Two Glasgow

Transcription

1 MEDICINE, MARKETS AND MORALS Network Abstracts Meeting Two Glasgow Jan Abel Olsen - Reducing inequalities in what? The Norwegian priority setting commissions views on prospective shortfall vs total shortfall Policy objectives in most publicly funded national health services relate to efficiency as health maximization, and equity in the distribution of health gains. The more a health care programme contributes to the reduction in inequality, the more valuable it is, and hence, the more would society be willing to pay for the programme. The critical question then is which type of health inequalities are to be reduced, i.e. equality of what? Different countries have been influenced by different equity criteria. This paper will outline four criteria: i) prognosis (e.g. the end-of-life argument in the UK); ii) relative shortfall (proposed in the Netherlands); iii) absolute (prospective) shortfall, and; iv) lifetime (total) shortfall. The last two criteria have recently been on the health policy agenda in Norway. They differ as to whether past health losses are considered priority relevant. An analytical framework is presented to compare and illustrate the key differences across the four criteria. This is followed by a normative discussion, emphasizing the discourse on prospective vs total shortfall. It is shown that a lifetime approach to shortfalls is less ageist and more favourable to the chronically ill patients than is the prospective approach inherent in the absolute shortfall criterion. Meindert Boysen - NICE; a bit economical with (health) economics? Ever since 1999 NICE has operated at the centre of the debate around what might be considered reasonable allocation of scarce healthcare resources. Over these fifteen years, we have appraised more than 500 technologies; pharmaceutical, medical devices, and diagnostics. While our methods have become ever more sophisticated, our procedural principles continue to ensure the buy-in from our broad range of stakeholders. Although particularly well known for our focus on cost effectiveness, and the accompanying threshold, we have consistently approached our job through an emphasis on structured decision making and the moral concept of 'accountability for reasonableness'. Developments in recent years have focussed on creating greater flexibility for our advisory committees to recognise the particular challenges in the appraisal of life extending technologies at the end of life. This policy, together with the Cancer Drugs Fund, have often been described by policy makers as a bridge to 'value based pricing'. Although the concept of value based pricing didn't find itself into the 2014 Pharmaceutical Price Regulation Scheme, NICE was asked to further develop 'value based assessment'. Initial explorations, in 2014, led us to conclude that although there may be some scope for the consideration of 'burden of illness' as a potential modifier for the consideration of differential value of health technologies, there was no platform for the structural consideration of societal impact of technologies. Concerns for potentially unacceptable distributional effects, and for the need to consider these concepts both in the appraisal of the new

2 intervention and in the estimation of opportunity cost, underpinned the need for further exploration. NICE is actively pursuing this. Olivia Butterworth - To explore the role of citizens and communities in shaping, developing and delivering health and care services: The NHS and Care services are under significant pressure from a range of factors; increasingly specialised and cutting edge healthcare; increased lifestyle factors impacted by social determinants and health inequalities; financial pressures and mixed economies; increasingly complex commissioner and provider relationships and responsibilities. How can we work with and connect to citizens and communities in more meaningful ways where we can both understand the offer (assets) they have to contribute to health and care services and also in empowering and enabling people to manage their own and their families health and wellbeing. NHS Citizen has been exploring how digital democracy can create different conversations and connections that can lead to a shift in the dialogue between the citizen and the system. Francesca Calo - Developing an evaluation framework for a communitybased social enterprise health initiative in rural Scotland This paper provides an overview of a PhD which aims to assess the evidence base for social enterprise, community health initiatives operating in rural settings in advanced economies. Since the late 1990s the concept of 'social enterprise' has achieved policy recognition in many countries as part of attempts to reform health and social care systems. However, this has been accompanied by demands from policy makers for greater accountability, transparency and demonstration of social impact, thus supporting evidence-based decisions and for redirecting budgets and funding. In recent decades, different instruments have been developed in non-profit management, social entrepreneurship and the programme evaluation literature for understanding the results and contribution of such social businesses.. However, there is still a lack of evidence on the role of social enterprise, and, specifically, there is a scarcity of primary evidence based data on health outcomes. Therefore, it is important to improve the evidence base, in particular in publicly-funded health and social care settings. Consequently, the following overarching question is particularly important for researchers, practitioners and policy makers: How can such organisations measure and demonstrate their social impact in comparison with other providers (such as the public sector and other non-profits)? This leads to the three more specific questions to be explored in the research: What does a systematic review of the literature tell us about the quality of the evidence base with respect to whether social enterprise provides improved outcomes in comparison with private-for-profit and public providers in health and social care systems? What is the feasibility of improving the evidence base via a controlled comparative study of a community-based, health-focussed social enterprise initiative? What mechanisms and environment might support (or impede) the production of positive outcomes from such social enterprise environment? The latter two questions are being investigated within the context of a particular community health initiative, operating on social enterprise principles, in a rural setting in the West of Scotland. Moreover a specific focus on challenges and difficulties behind the research will be highlighted, in order to set a comprehensive research agenda for future studies. 2

3 Marissa Collins & Michael Roy - Creating the Conditions for Health: The Role of the Third Sector The focus of this talk will be about the role of the third sector from different perspectives. One perspective being, from work done in conjunction with the Glasgow Council for the Voluntary Sector, to evaluate the impact of third sector activity on Rebalancing Care for Older People and how this work seeks to augment healthcare provision, particularly at the local level. Another perspective is to look at social enterprise part, a sub-sector of the third sector, and how social enterprises - all social enterprises - can be conceptualised as non-obvious public health actors. Kara Hanson - Moving towards a purchasing model in low- and middleincome countries Universal health coverage (UHC), which means that everyone has access to the services they need, at acceptable quality, without financial hardship, is one of the targets agreed for the Sustainable Development Goal for health. Many low- and middle-income countries are developing their plans to expand coverage along the three main dimensions of UHC (population coverage, service coverage, financial coverage). Strategic purchasing has been proposed as an important means of linking pooled funds, collected on behalf of an insured population, with health care providers, in ways which will ensure equity, efficiency and financial protection. We undertook a critical analysis of purchasing arrangements in 10 low- and middle-income countries in Africa and Asia, examining a range of purchasers (public integrated, public contracting, and private contracting models). In this presentation I will describe the purchasing arrangements in some of these settings, assess progress and performance, and identify some of the key challenges in moving towards a more strategic approach to healthcare purchasing. Nathan Hodson - The impact of healthcare marketization on the acceptability of behavioural insights Behavioural Insights are increasingly perceived by policy makers as a panacea in the field of getting people to do what you want them to. Also known as nudges, they encompass a variety of approaches to promoting preferred behaviours without prohibition or major financial incentivization. They are highly targeted and rigorously tested in randomized-controlled trials. This presentation will outline the different types of nudge and divide them along lines of interference and intention. The arguments for and against the use of behavioural insights in the NHS will be appraised. Justifications which work in the NHS are less compelling within a marketized model of healthcare. An alternative defence of nudging in healthcare based on patient responsibilities outlined in the NHS Constitution will be proposed on the basis that it would be better suited to shifting models of healthcare provision. The conceptual challenges of such an approach will be explored. Eleanor MacKillop - Quantifying quality of life: explaining the origins of Quality-Adjusted Life-Years Among the various ideas and processes formulated by health economics since the 1960s, Quality- Adjusted Life-Years (QALY) and other Quality of Life (QOL) measurements are often considered as the most path-breaking and influential ones over health systems, health care management and health policy-making (Forget 2004; Grosse 2008; Hurst 1998; Rosser 1993; Williams 2005; Zeckhauser & Shephard 1976). Yet, these measurements and their benefits to the allocation of resources and the improvement of quality of life of patients have been and remain the subject of disputes (Koch 2000; Mulkay et al. 1987; Nord 2001). 3

4 In understanding the current popularity of these concepts, it is important to delve back into the making of this practice, whose emergence goes hand in hand with that of health economics in British policy-making and elsewhere. Based on a review of the historiography of QALY and QOL, I argue that the literature tends to be sparse and to present a uni-dimensional story of the emergence of these measurements. Instead, building on ideas developed in the policy network and advocacy coalition frameworks (Richardson & Jordan 1979; Sabatier & Weible 2014), I propose a more multifaceted picture of this birth, intertwined with debates and events on both sides of the Atlantic, and accounting for the sudden growth in interest from the political class for such practices of costcontainment and priority-setting. In doing so, I focus on two often antithetical themes which have been and remain central to discussions of QALY: cost and ethics. What is concluded is that the history of health economics, and of QALY in particular, should endeavour to be more complex, emphasising the conflicts in its emergence, in order to inform current debates over costs and ethics in health care provision (Oliver 2005). References: Forget, E.L., Contested Histories of an Applied Field: The Case of Health Economics. Journal of Policy Economy, 36(4), pp Grosse, S.D., Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert review of pharmacoeconomics & outcomes research, 8(2), pp Hurst, J., The impact of health economics on health policy in England, and the impact of health policy on health economics, Health Economics, 7 Suppl 1, pp.s Koch, T., Life quality vs the quality of life : Social Science & Medicine, 51(3), pp Mulkay, M., Ashmore, M. & Pinch, T., Measuring the Quality of Life: A Sociological Invention Concerning the Application of Economics to Health Care. Sociology, 21(4), pp Nord, E., The desirability of a condition versus the well being and worth of a person. Health economics, 10(7), pp Oliver, A., Personal histories in health research, London. Richardson, J. & Jordan, G., Governing Under Pressure. The Policy Process in a Postparliamentary Democracy, Oxford: Martin Robertson. Rosser, R., The history of health related quality of life IN 10 1/2 paragraphs. Journal of the Royal Society of Medicine, 86(6), pp Sabatier, P. & Weible, C., The Advocacy Coalition Framework: Innovations and Clarifications. In P. Sabatier & C. M. Weible, eds. Theories of the Policy Process. Boulder, CO: Westview Press, pp Williams, A., Discovering the QALY, or how Rachel Rosser changed my life. In A. Olver, ed. Personal Histories in Health Research. London: The Nuffield Trust, pp Zeckhauser, R. & Shephard, D., Where now for saving lives. Law and Contemporary Problems, 40(4), pp Julian Sheather Markets and medical professionalism In this presentation I will be exploring the impact of commercial and market-based models of NHS healthcare delivery on medical professionalism. Although professionalism is a loose concept, not amenable to precise definition, I will set out a working definition rooted in a core set of professional patient-oriented dispositions. I will then discuss the potential impact of 'marketisation' on these attitudes or dispositions. In order to do this I will identify three partly linked questions or areas of interest. Markets and the rise of conflicts of interests in medicine 4

5 Can patient-oriented professionalism survive in a market? Should health care be a tradeable good? Given these challenges I will conclude by asking whether in the long term markets in health care are conducive to the development of the kinds of doctors that patients need. And if markets are unavoidable, how can unintended consequences be mitigated? Mark Sheehan - Do treatments for rare or very rare conditions need special consideration in the allocation of healthcare resources? I take as my starting point the idea that patients in a healthcare system should be treated equally, fairly and consistently. This means that both outcomes and opportunity matter. On the one hand, a healthcare system is required to use the resources it has in the best way. On this, equality of outcome approach, two treatments that have the same outcome ought to be resourced to the same extent. If treatment A has a better outcome than treatment B then (other things being equal) A should be prioritised over B. On the other hand, a healthcare system should ensure that people are given an equal opportunity at the best health possible for them. On this, equality of opportunity approach, each person, rather than their ability to be made healthy, is to be treated equally alongside other people. This means giving each person an equal opportunity at the best health possible for them. Both equality of outcome and equality of opportunity are important in the fair allocation of healthcare resources. However, on a single system of resource allocation (be it local, regional or national), those who suffer from conditions that are rare or very rare are systematically disadvantaged because they are deprived of an equal opportunity at a healthy life. This is because such a system cannot deal with the extreme range of cost and evidence related issues that the treatment of rare or very rare conditions raise. I argue in this presentation that a separate process of resource allocation for the treatment of rare or very rare conditions and which has a settled, ring-fenced budget would be well placed to ensure that equality of opportunity at health is provided for this group in a way that is consistent with the other principles of fair healthcare resource allocation. Ellen Stewart - Public involvement in healthcare priority-setting: bringing in uninvited action Discussions of public involvement in difficult healthcare resource allocation decisions tend to start from the perspective of commissioning organisations: how can we best involve the public in this decision? There is a rapidly growing evidence base on the range of methods which organisations use to involve people. However when it comes to contentious priority-setting decisions which also have a high degree of public visibility, commissioners are likely to attract uninvited action from members of the public, including protest activities and attempts to bring elected politicians into the debate. Existing conceptual accounts of public participation in healthcare are much less able to account for this type of action, which can significantly destabilise decision-making processes. Drawing on international published literature about public responses to hospital closures, and Tilly s analysis of contentious politics this paper elaborates a framework of public tactics in response to proposals to close hospitals. I argue that we need to better understand both how publics mobilise and choose particular tactics, and how organisations respond to and manage those challenges. 5

6 Attila Tanyi - A reasons-based approach to the ethics of prioritisation The paper has three parts. In the first part, the aim is to clarify the conceptual landscape of rationing. This consists in delineating the concept, aim and scope of rationing in health care. Thus the paper contrasts the ethical question of rationing with the question whether the state has an obligation to provide its citizens with health care resources. Unlike the latter question, rationing offers an ethical challenge also in exclusively private health care systems. The next issue is what exactly we ration. The paper here argues for its relatively narrow focus: it does not discuss rationing in the wider context of what competing state services require, nor is it interested in the so-called social determinants of health. The focus is on the macro-allocation (as opposed to micro-allocation) of health care resources only. In the second part, the paper introduces and briefly analyses the most influential theories of this form of rationing: the focus is on the utilitarian, communitarian, egalitarian approaches and on fair democratic procedures. Finally, in the third part, the paper puts forward a novel approach to rationing that is reason-based. The idea is to allocate according to the balance of reasons supporting demands for health-care resources. What becomes crucial here, the paper argues, is which theory of reason one makes use of. Since there are roughly two camps in this field reasons are either desire-based or value-based the primary challenge of this approach is to work out the implications of these two theories for the rationing of health-care resources. 6