Modular update: Equality and health inequality impact assessment (EHIA)
Open for comments Open until Request commenting lead permission
We have updated this service so that members of the same organisation can now collaborate on a joint online response.
Read our blog to learn more.
3 Impact and mitigation
Table 1 describes the impact of the EQ-5D-5L value set on populations with protected characteristics or wider determinants of poor health, and our proposed mitigations.
Protected characteristic or wider determinant of health | Impact | Mitigation |
|---|---|---|
Comments across all equality strands | Adopting the 5L value set into NICE methods will affect all recommendations for which the reference case requires a cost–utility analysis. This is because cost–utility analyses require an assessment of health-related quality of life, and because NICE selected the EQ-5D as its preferred measure of health-related quality of life to ensure consistency across evaluations. The 5L value set will be applied equally across technology appraisals and highly specialised technology evaluations for adults, as well as HealthTech evaluations and guidelines that require a cost–utility analysis, regardless of the intervention under evaluation. But, we recognise that this is likely to have a disproportionate adverse impact on a group of people sharing the protected characteristic of disability (specifically, those with conditions for which treatments do not affect how long people live and might become less cost effective after adopting the 5L value set). Groups with other protected characteristics, as well as groups with wider determinants of poor health, may also be negatively affected by adopting the 5L value set, because treatments for conditions more common in these groups may become less cost effective. There is also some indication that adopting the 5L value set may be less favourable for young people than for older people, although the evidence supporting this conclusion is limited. These impacts are discussed in section 2. Notwithstanding the impact assessment identifying the potential for indirect discrimination for some groups of people, adopting the 5L value set reflects an evidence-based improvement to NICE's methods and will allow us to more accurately estimate the health benefits and cost effectiveness of new technologies consistently across our evaluations, regardless of the condition being treated. The 5L value set reflects current societal preferences about what people consider important about their health. Much has changed since the 3L value set was created in the 1990s: the UK population demographics are different, healthcare has advanced, public awareness of health issues has evolved, and the methods used to develop value sets have improved significantly. Health technology assessment agencies in several other countries have adopted their local 5L value set. Some groups of people are also likely to be positively affected by adopting the 5L value set. These include people with cancer, which is classed as a disability under the Equality Act 2010, and conditions for which treatment benefits are driven by extending how long people live. Based on the sample in EEPRU's analysis, treatments became more cost effective with the 5L value set for the following disabling conditions (references provide information about when the condition could qualify as a disability):
| We recognise the disadvantage caused to some groups of people. We will provide committees with briefing materials and training, including information on the impact of adopting the 5L value set, drawing attention to the populations (and related equalities and health inequalities issues) that could potentially be negatively affected because treatments might become less cost effective. We will also explain the potential impact of adopting the 5L value set on the severity weightings applied in technology appraisal decisions. As part of these briefing materials and training, we will promote awareness of:
NICE's current processes ensure that equalities and health inequalities are considered and addressed during the development of every NICE evaluation and guideline. Stakeholders and experts with relevant expertise are explicitly asked to identify relevant issues, and NICE publishes the outputs of our equality and health inequalities impact assessments for every evaluation, guideline and guideline update. Committees consider equalities issues and the health inequality impacts of a technology when making recommendations in technology appraisals, highly specialised technology evaluations and guidelines (see sections 6.1.2, 6.2.35 to 6.2.38, and 6.3.5 of NICE's technology appraisal and highly specialised technologies guidance manual [presented in appendix B] and section 9.1 of the developing NICE guidelines manual [presented in appendix C]). For interventions that reduce health inequalities, committees can apply flexibility to the range of ICERs normally considered a cost-effective use of NHS resources. To help address equality issues, committees can also make optimised recommendations (with different recommendations for specific groups) and recommendations for research. NICE manuals recognise that in some circumstances the EQ-5D may not be the most appropriate measure for capturing health-related quality of life. These include when evidence generation is difficult (for example, for rare diseases) or the nature of the condition means that the EQ-5D performs poorly and is not responsive to changes for particular people. Committees can accept evidence from other health-related quality of life measures, including generic or condition-specific measures, if evidence is provided to show that the EQ-5D is not appropriate (see sections 4.3.9 to 4.3.12 of NICE's technology appraisal and highly specialised technologies guidance manual, presented in appendix D). |
Age | The EQ-5D is NICE's preferred measure of health-related quality of life for adults, and our manuals do not recommend specific measures of health-related quality of life in children and young people. The EQ-5D-5L measure and its value set are designed specifically for use in adults only, so this methods update does not cover children and young people. High-quality research examining methods for measuring and valuing health-related quality of life in children and young people is required to inform updates to our methods guidance. This will be identified and considered using NICE's published process for identifying and prioritising modular updates. Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's finding that treatments that did not affect how long people with non-cancer conditions live became less cost effective). People with some of these conditions are more likely to belong to certain age groups:
The DSU analysis identified a link between age and the impact of the 5L value set on the calculations that inform whether a treatment qualifies for the severity weighting. Using the 5L value set resulted in larger reductions in both AS and PS for populations with younger average starting ages in the cost-effectiveness models. This seems to suggest that adopting the 5L value set may be less favourable for younger people than for older people. That is, younger people may be less likely to receive the severity weighting. But, the DSU analysis did not identify any evidence that the severity weighting is systematically worse for younger patients when using the 5L value set. In the 2 technology appraisal decisions that had a lower severity weighting with the 5L value set, 1 was in younger people (average starting age of 4 years) and the other was in older people (average starting age of 60 years). The DSU analysis concluded that changes in AS and PS resulting from using the 5L value set are unlikely to reduce the severity weighting in the vast majority of cases, so the risk of indirect discrimination based on age is low. We consider the risk of indirect discrimination to be justified for the reasons previously outlined. That is, adopting the 5L value set reflects an evidence-based methods improvement that will allow NICE to more accurately estimate the health benefits and cost effectiveness of new interventions consistently across our evaluations, regardless of the condition. It will be applied equally to all technology appraisals and other guidance requiring a cost–utility analysis. | As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. Equalities issues related to age that are relevant to an appraisal or guideline will be identified and addressed using NICE's existing processes and methods, including consideration of whether any reasonable adjustments are needed. These will be captured in our published equality impact assessments and, where appropriate, in final NICE guidance. |
Disability | People are considered disabled under the Equality Act 2010 if they have a 'physical or mental impairment that has a "substantial" and "long-term" negative effect on your ability to do normal daily activities'. People diagnosed with cancer, HIV infection or multiple sclerosis automatically meet the disability definition under the Equality Act 2010. People with other conditions may also meet the definition, depending on the severity and duration of their condition. Several populations could be negatively affected by adopting the 5L value set (based on EEPRU's findings that treatments which did not affect how long people with non-cancer conditions live became less cost effective). Some of these conditions could be classed as disabling, depending on their impact on a person's ability to do normal daily activities. This includes people with multiple sclerosis, Duchenne muscular dystrophy and ulcerative colitis. Conversely, some conditions which are classed as disabling are likely to be positively impacted by adopting the 5L value set. In particular, treatments for cancer are likely to become more cost effective after adopting the 5L value set. We recognise that adopting the 5L value set could lead to indirect discrimination by placing some disabled people (those with conditions for which treatments do not extend how long they live and may become less cost effective) at a disadvantage compared with people who are not disabled. We consider that this risk of indirect discrimination is justified for the reasons previously outlined. That is, adopting the 5L value set reflects an evidence-based methods improvement that will allow NICE to more accurately estimate the health benefits and cost effectiveness of new interventions consistently across our evaluations, regardless of the condition. It will be applied equally to all technology appraisals and other guidance requiring a cost–utility analysis. | As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some disabled persons. Equalities issues related to disabilities that are relevant to an appraisal or guideline will be identified and addressed using NICE's existing processes and methods, including consideration of whether any reasonable adjustments are needed. These will be captured in our published equality impact assessments and documented, where appropriate, in final NICE guidance |
Race or ethnicity | Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's findings that treatments which did not affect how long people with non-cancer conditions live became less cost effective). Some of these conditions are more common in people of certain races or ethnicities. These include the following:
Diagnostic and assessment tests for the following conditions can be less accurate for people with darker skin, and treatments for these conditions might become less cost effective as a result of adopting the 5L value set (based on EEPRU's finding that treatments that do not affect how long people live became less cost effective):
| As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. Equalities issues related to race or ethnicity that are relevant to an appraisal or guideline will be identified and addressed using NICE's existing processes and methods, including consideration of whether any reasonable adjustments are needed. These will be captured in our published equality impact assessments. |
Gender reassignment | No impact identified. | – |
Marriage and civil partnership | No impact identified. | – |
Pregnancy and maternity | No impact identified. | – |
Religion and belief | Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's finding that treatments that did not affect how long people with non-cancer conditions live became less cost effective). Some of these conditions disproportionately affect people from certain faith groups, as follows:
| As previously mentioned, we will brief committees on the impact of adopting the 5L value set and will remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. Equalities issues related to religion or belief that are relevant to an appraisal or guideline will be identified and addressed using NICE's existing processes and methods, including consideration of whether any reasonable adjustments are needed. These will be captured in our published equality impact assessments and documented, where appropriate, in final NICE guidance |
Sex | Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's finding that treatments which did not affect how long people with non-cancer conditions live became less cost effective). Some of these conditions are more common depending on biological sex. Some conditions more common in females are:
Haemophilia A and B primarily affect males (NICE technology appraisal 1051, 2025). | As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. Equalities issues related to sex that are relevant to an appraisal or guideline will be identified and addressed using NICE's existing processes and methods, including consideration of whether any reasonable adjustments are needed. These will be captured in our published equality impact assessments and documented, where appropriate, in final NICE guidance |
Sexual orientation | No impact identified. | – |
Socioeconomic deprivation (This is not a protected characteristic under the Equality Act 2010, but is a determinant of poor health. It includes variation in deprivation by location such as Index of Multiple Deprivation, National Statistics Socio-economic Classification, employment status and income.) | Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's finding that treatments which did not affect how long people with non-cancer conditions live became less cost effective). This includes people with conditions linked to lower socioeconomic status, such as:
People with some conditions need to travel to specialist centres to access treatments (see 'Geographical area variation' section). This may limit access to treatment for people from deprived backgrounds. | As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. |
(This is not a protected characteristic under the Equality Act 2010, but is a determinant of poor health. It includes geographical differences in epidemiology or service provision, for example urban or rural, coastal, north or south.) | Our review indicates that some populations could be negatively affected by adopting the 5L value set (based on EEPRU's findings that treatments which do not affect how long people live became less cost effective) because they need to travel to specialist centres for treatment. These include people with:
| As previously mentioned, we will brief committees on the impact of adopting the 5L value set and remind them of:
These mitigations will act as reasonable adjustments to avoid the disadvantage caused to some groups of people. |
Inclusion health groups and vulnerable groups (This is not a protected characteristic under the Equality Act 2010, but is a determinant of poor health. It includes vulnerable migrants, people experiencing homelessness, people in contact with the criminal justice system, sex workers, Gypsy, Roma and Traveller communities, young people leaving care and victims of trafficking.) | No impact identified. | – |
How are you taking part in this consultation?
You will not be able to change how you comment later.
You must be signed in to answer questions