NICE’s Social Value Judgments about Equity in Health and Health Care

The National Institute for Health and Clinical Excellence (NICE) routinely publishes details of the evidence and reasoning underpinning its recommendations, including its social value judgments. To date, however, although the principles related to cost-effectiveness are relatively explicit, those covering equity concerns generally are less specific.

Koonal Shah

The National Institute for Health and Clinical Excellence (NICE) routinely publishes details of the evidence and reasoning underpinning its recommendations, including its social value judgments. To date, however, although the principles related to cost-effectiveness are relatively explicit, those covering equity concerns generally are less specific. NICE takes a pragmatic, case-based approach to developing its principles of social value judgment, drawing on the cumulative experience of its advisory bodies in making decisions that command respect among its broad and diverse range of stakeholders.

In a University of York CHE Research Paper, OHE’s Koonal Shah collaborated with Richard Cookson, Tony Culyer and Peter Littlejohns to examine the inclusion of social value judgments in NICE guidance decisions and describe the social value judgments about equity in health and health care that NICE has used to guide its decision making to date.  Reviewed are both information on general social value judgments included in NICE guidance on methodology and case-specific social value judgments contained in NICE guidance about specific health care technologies and public health interventions.

The paper provides a brief overview of why NICE has implemented a policy of transparency for social value judgments, and why its social value judgments about cost-effectiveness are more specific than those about equity. It describes NICE’s social value judgments about three different types of equity concerns: (1) that health services be distributed according to need, (2) that health service recipients not experience discrimination based on personal or social characteristics, and (3) that unfair health inequalities be reduced.

For each of these three equity concerns, the authors have sought out both statements and suggestions in NICE guidance where social value judgments may have been applied. Although specific cases are identified for the first of these – need – they are largely absent for discrimination and health inequalities for reasons detailed in the paper.

According to the authors, “Our central finding is that, although NICE advisory bodies are authorised to depart from the social value judgment that ‘a QALY is a QALY is a QALY’ on grounds of equity, they have in practice been extremely reluctant to do so explicitly except in the special case of life-extending end of life treatments.” They note, however, that advisory bodies implicitly have taken into account a range of equity considerations, without explicitly affecting the weighting of QALY gains.

It remains to be seen, according to the authors, whether NICE’s advisory bodies will take decisions on equity grounds in the future that explicitly imply a special additional weight on QALY gains for any population subgroup. The authors believe that the reluctance of advisory bodies to do so is “understandable, given the complex and politically controversial nature of equity concerns. An explicit decision that departs from current practice by giving explicit additional weight to QALY gains for a particular population group carries substantial risks of intense media attention, protracted legal appeals, and the setting of unhelpful precedents.”

As the authors note, giving “special additional weight to QALY gains” for any one subgroup – however determined – also logically implies a lower weight for those outside that subgroup.  For example: giving greater weight to QALY gains for socio-economically disadvantaged populations implies that QALY gains for socio-economically advantaged populations should be lower; and greater weight for the severely ill implies lower weight for those not severely ill.

In theory, the authors note, it should be possible to avoid such potentially uncomfortable implications by developing a “nuanced and context-sensitive set of general QALY weighting principles”.  In practice, however, several practical considerations mitigate against that, producing for NICE a “pragmatic, incremental approach in which social value judgments are developed in an iterative process through cumulative case-based experience and only later (if at all) codified into general principles”.  Nevertheless, they conclude, the fact that “NICE has explicitly identified so many of the issues and opened them up for research and public discussion must be counted as remarkable pioneering achievements not to be found elsewhere in decision making, in the UK or anywhere else, about public investments. It is surely an experience from which similar agencies elsewhere might usefully learn”.

Shah, K.K., Cookson, R., Culyer, A. and Littlejohns, P. (2011) NICE’s social value judgments about equity in health and health care. CHE Research Paper 70. York: University of York.  Available for download from the University of York website.

Related OHE research

Download: Shah, K.K., Wailoo, A. and Tsuchiya, A. (2011) Valuing health at the end of life: An exploratory preference elicitation study. OHE Research Paper 11/06. London: Office of Health Economics.

Download: Shah, K.K., Praet, C., Devlin, N.J., Sussex, J.M., Appleby, J. and Parkin, D. (2011) Is the aim of the health care system to maximise QALYs? An investigation of ‘what else matters’ in the NHS. OHE Research Paper 11/03. London: Office of Health Economics.