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We need to talk about values: a proposed framework for the articulation of normative reasoning in health technology assessment
- Victoria Charlton, Michael DiStefano, Polly Mitchell, Liz Morrell, Leah Rand, Gabriele Badano, Rachel Baker, Michael Calnan, Kalipso Chalkidou, Anthony Culyer, Daniel Howdon, Dyfrig Hughes, James Lomas, Catherine Max, Christopher McCabe, James F. O'Mahony, Mike Paulden, Zack Pemberton-Whiteley, Annette Rid, Paul Scuffham, Mark Sculpher, Koonal Shah, Albert Weale, Gry Wester
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- Journal:
- Health Economics, Policy and Law , First View
- Published online by Cambridge University Press:
- 27 September 2023, pp. 1-21
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- Article
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It is acknowledged that health technology assessment (HTA) is an inherently value-based activity that makes use of normative reasoning alongside empirical evidence. But the language used to conceptualise and articulate HTA's normative aspects is demonstrably unnuanced, imprecise, and inconsistently employed, undermining transparency and preventing proper scrutiny of the rationales on which decisions are based. This paper – developed through a cross-disciplinary collaboration of 24 researchers with expertise in healthcare priority-setting – seeks to address this problem by offering a clear definition of key terms and distinguishing between the types of normative commitment invoked during HTA, thus providing a novel conceptual framework for the articulation of reasoning. Through application to a hypothetical case, it is illustrated how this framework can operate as a practical tool through which HTA practitioners and policymakers can enhance the transparency and coherence of their decision-making, while enabling others to hold them more easily to account. The framework is offered as a starting point for further discussion amongst those with a desire to enhance the legitimacy and fairness of HTA by facilitating practical public reasoning, in which decisions are made on behalf of the public, in public view, through a chain of reasoning that withstands ethical scrutiny.
four - Did NHS productivity increase under the Coalition government?
- Edited by Mark Exworthy, University of Birmingham, Russell Mannion, University of Birmingham, Martin Powell
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- Book:
- Dismantling the NHS?
- Published by:
- Bristol University Press
- Published online:
- 05 April 2022
- Print publication:
- 28 July 2016, pp 65-86
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Summary
Introduction
In the light of seemingly inexorable pressures to increase NHS expenditure year on year, it is not surprising that the productivity of the health system looms large in political debate. It has long been argued that the impacts of an aging population and the development of new technologies place ever greater demands on the health system. The question is whether these demands should translate directly into greater allocation of resources, or whether better use can be made of the resources already devoted to the NHS though improved productivity. Unsurprisingly, politicians presume that there is scope for the latter, and in the first section of this chapter we summarise some of the key political measures claimed to promote NHS productivity improvements over the past ten years.
Productivity is a conceptually simple construct, relating the amount of output produced to the amount of inputs used in the production process. NHS outputs include the amount and quality of care provided to patients. Inputs include the number of doctors, nurses and support staff providing care, the equipment and clinical supplies used, and the hospitals and other premises where care is provided. This ratio of outputs to inputs can be constructed at national level to assess the productivity of the entire NHS or of different parts of the system, or sub-nationally to look at the productivity of hospitals or other organisations engaged in producing health care. The productivity ratio simply divides outputs by inputs at any particular point of time. Productivity growth can also be calculated, by comparing the change in outputs produced to the change in inputs utilised from one period to the next. Political interest is focused primarily on productivity growth. Maximising productivity is a necessary but not sufficient condition for attaining overall efficiency: merely maximising output from available inputs does not necessarily imply an optimum mix of outputs. Assessing this broader concept of efficiency is, however, problematic in the context of a free-at-the-point-of-use health service such as the NHS, where willingness to pay for the output generated is not directly assessed by the conventional means of market prices. As individuals are not able to forgo NHS outputs – treatment – in order to purchase other goods in a market, we cannot directly assess in this conventional sense the overall economic efficiency of the health service. Our approach is therefore a narrower, but valuable, assessment of the outputs produced from the health service's inputs.