Equity versus efficiency: a dilemma for the NHS

Sassi, Franco; Grand, Julian Le; Archard, Luke

doi:10.1136/bmj.323.7316.762

Cited by 48 publications

(28 citation statements)

References 6 publications

(9 reference statements)

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“…25 The NHS is currently characterised by pressures for both competition and collaboration. Although the Health and Social Care Act 2012 26 requires competition and collaboration, the two are often at variance; when they conflict, some commentators argue that competition will dominate.…”

Section: Contribution and Significance Of The Researchmentioning

confidence: 99%

Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy

Llewellyn

Chambers

Ellwood

et al. 2016

Health Serv Deliv Res

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BackgroundTraditionally, the cost object in health care has been either a service line (e.g. orthopaedics) or a clinical intervention (e.g. hip replacement). In the mid-2000s, the Department of Health recommended that in the future the patient should be the cost object, to enable a better analysis of cost drivers in health care, resulting in patient-level information and costing systems (PLICSs). Monitor (the economic regulator for health care) proposes that PLICS data will now form the basis for mandatory prices for health-care services across all care settings.ObjectiveOur main aim was to investigate the use of PLICSs.MethodsWe surveyed all English foundation trusts and NHS trusts, and undertook four case studies of foundation trusts. Three trusts were generalist and one was specialist. We also surveyed commissioning support units to explore the potential for PLICSs in commissioning.FindingsThe most significant use of PLICSs was cost improvement within the trusts. There was only modest utilisation of PLICSs to allocate resources across services and settings. We found that trusts had separate reporting systems for costs and clinical outcomes, engendering little use for PLICSs to link cost with quality. Although there was significant potential for PLICSs in commissioning, 74% of survey respondents at trusts considered their PLICS data to be commercially sensitive and only 5% shared the data with commissioners. The use of PLICSs in community services was, generally, embryonic because of the absence of units of health care for which payment can be made, service definitions and robust data collection systems. The lack of PLICS data for community services, allied with the commercial sensitivity issue, resulted in little PLICS presence in collaborative cross-organisational initiatives, whether between trusts or across acute and community services. PLICS data relate to activities along the patient pathway. Such costs make sense to clinicians. We found that PLICSs had created greater clinical engagement in resource management despite the fact that the trust finance function had actively communicated PLICSs as a new costing tool and often required its use in, for example, business cases for clinical investment. Operational financial management at the trusts was undertaken through service line reporting (SLR) and traditional directorate budgets. PLICSs were considered more of a strategic tool.ConclusionsBoth PLICSs and SLR identify and interrogate service line profitability. Although trusts currently cross-subsidise to support loss-making areas under the tariff, they are actively considering disinvesting in unprofitable service lines. Financial pressure within the NHS, along with its current competitive, business-oriented ethos, induces trusts to act in their own interests rather than those of the whole health economy. However, many policy commentators suggest that care integration is needed to improve patient care and reduce costs. Although the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. London: The Stationery Office; 2012) requires both competition and the collaboration needed to achieve care integration, the two are not always compatible. We conclude that competitive forces are dominant in driving the current uses of PLICSs. Future research should interrogate the use of PLICSs inNew Care Models – Vanguard Sites(NHS England.New Care Models – Vanguard Sites. NHS England; 2015) and initiatives to deliver the ‘Five Year Forward View’ (Monitor and NHS England.Reforming the Payment System for NHS Services: Supporting the Five Year Forward View. London: Monitor; 2015).FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Contribution and Significance Of The Researchmentioning

confidence: 99%

Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy

Llewellyn

Chambers

Ellwood

et al. 2016

Health Serv Deliv Res

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“…Sassi et al, 2001b), and the use of cost-effectiveness analysis in health care is now widespread. The UK Department of Health has to ensure that public money is spent wisely and efficiently, with the expenditure on health and social care expected to represent value for money (www.dh.gov.uk).…”

Section: Value For Moneymentioning

confidence: 99%

Exploring the social value of health‐care interventions: a stated preference discrete choice experiment

2008

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SUMMARYMuch of the literature on distributive preferences covers specific considerations in isolation, and recent reviews have suggested that research is required to inform on the relative importance of various key considerations. Responding to this research recommendation, we explore the distributive preferences of the general public using a set of generic social value judgments. We report on a discrete choice experiment (DCE) survey, using face-to-face interviews, in a sample of the general population (n 5 259). The context for the survey was resource allocation decisions in the UK National Health Service, using the process of health technology appraisal as an example. The attributes used covered health improvement, value for money, severity of health, and availability of other treatments, and it is the first such survey to use cost-effectiveness in scenarios described to the general public. Results support the feasibility and acceptability of the DCE approach for the elicitation of public preferences. Choice data are used to consider the relative importance of changes across attribute levels, and to model utility scores and relative probabilities for the full set of combinations of attributes and levels in the experimental design used (n 5 64). Results allow the relative social value of health technology scenarios to be explored. Findings add to a sparse literature on 'social' preferences, and show that DCE data can be used to consider the strength of preference over alternative scenarios in a prioritysetting context.

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“…In the context of limited resources, the equity versus efficiency trade-off is a major issue when prioritize health care. There is no consensus on how to balance equity with efficiency within the Nasional Health System, leading [37], to argue that the trade-off has led to "inconsistent judgements in the development of health policy" and to appeal for guidance from the Nasional Health System when equity and efficiency conflict.…”

Section: Regulations and Budget Constraints As Determinants In Hummentioning

confidence: 99%

“…In fact, it is most often assumed that there is a trade-off between equity, economy, and efficiency. [37], [38]. In the context of limited resources, the equity versus efficiency trade-off is a major issue when prioritize health care.…”

Section: Regulations and Budget Constraints As Determinants In Hummentioning

confidence: 99%

Humanity Governance at local level: A case in Insurance Program for Tappers in Indonesia

Kurniasih¹

2017

Proceedings of the International Conference on Ethics in Governance (ICONEG 2016)

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Abstract-Local potency development becomes a substantial aspect to improving local competitiveness. Indonesia leading sector commodity is palm sugar. Its production depends on worker productivity known as penderes or tappers (a man who take coconut water for making a palm sugar). Their job has a high risk, so that they need financial aid. The local government (Banyumas) has launched Insurance Program for tappers to respond it. This article discusses about the implementation of insurance programs for tappers in human governance perspective, which includes social accountability, ethics and moral principles. Besides that there were two determinant factors to reach humanity governance; they are about regulation and budget constraints.

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Equity versus efficiency: a dilemma for the NHS

Cited by 48 publications

References 6 publications

Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy

Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy

Exploring the social value of health‐care interventions: a stated preference discrete choice experiment

Humanity Governance at local level: A case in Insurance Program for Tappers in Indonesia

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