13 June 2014

What social values should NICE consider when balancing fairness with efficiency?

We look at the social values that NICE should consider when balancing fairness with efficiency.

A firm plans to develop a new high-speed rail network that takes passengers directly from London to Newcastle in less than 2 hours.

The line will be quick, effective, create more jobs and boost the local economy by encouraging more people to buy property in and around Newcastle.

However, some complain that the benefits of the rail network may not be felt equally by everyone.

They point out that people who live along the route but not at either city, will have to spend more time and money getting to either station, and so will be unfairly disadvantaged.

Economists describe situations such as these as the ‘trade-off between equity and efficiency’ – where efficiency is seen as doing the most with the resources available, and equity as ensuring that the resources are distributed fairly.

While the example of the rail network might improve efficiency – through enhanced speed and travel times – it does not improve equity since not everyone will be able to benefit from the planned changes.

So given a climate of increasing resource pressures within the NHS and local government, how might we achieve a balance between equity and efficiency in the health and social care sector? And what values should be considered when trying to achieve this balance?

These were questions that NICE’s Citizens Council was asked to consider when they met last month. The Citizen’s Council is a group of 30 members of the general public which provide input into NICE’s work. Its views on the social values which affect a range of health and social care matters help inform NICE in developing its national guidance and standards.

At the meeting, the Citizens Council were presented with a number of scenarios across the health, public health and social care sectors.

They were then asked to a draw up a list of social values, and compare how they apply to all three sectors when balancing equity with efficiency.

Why does NICE need to consider social values?

Social values are an important component in the development of NICE’s guidance and quality standards.

While NICE bases its decisions on the best available evidence, sometimes this evidence is not of good quality or not necessarily complete.

Consequently, NICE has to make judgements. These can be scientific value judgements about interpreting the quality and significance of the data available. Alternatively, they can be social value judgements that relate to social issues rather than science.

Professor Sarah Garner, Associate Director for Research and Development at NICE, explains: “Our decisions aim to help improve the clinical and cost effectiveness of health and social care.

“In the absence of evidence, or in value judgements where there is no right or wrong answer, we need to be sure that the judgements we use reflect those of the general public.”

She added: “NICE is in the process of integrating how it develops its guidance and quality standards across health, public health and social are, so we would like to know what the public’s views are on what social values are similar for each area, and where they might differ.

“The Citizens Council’s views will then be used to update NICE’s Social Values Judgements document, which outlines principles for the development of NICE guidance.”

Improve the health of the many, or the few?

People in England and Wales are living longer than ever before, with life expectancy having increased steadily over the past 50 years.

In spite of this, inequalities in the health between rich and poor still exist, and are no better than they were 25 years ago. So while everyone’s health is improving in absolute terms, in relative terms poorer members of society still experience worse health outcomes than their richer counterparts.

For example, official statistics show that a child born in Mole Valley can expect to live a decade longer than one born in Hammersmith and Fulham, which is just 40 miles away.

Many comment that this is unacceptable in a society that ought to be fair and just.

Given this, the Citizens Council was asked to consider whether NICE should try to continue to improve public health for everyone, or reduce the gap in health inequalities between rich and poor.

Professor Mike Kelly, Director of the NICE Centre of Public Health, explains: “Smoking is a classic public health example of inequalities in public health.

“Smoking-related diseases are now a rarity among people in middle class and professional occupations. Most of the 80,000 smoking-related deaths occur among those who are socially disadvantaged.

“So, a challenge to the public health sector is whether the gradient in health outcomes should be reduced between rich and poor, or whether health should be improved for everyone.”

However, given the significant tax revenue tobacco incurs, some say that tackling smoking is an inefficient use of resources. Others argue that targeting smokers in particular is in a sense victimising this sector of society. In addition, some suggest that healthcare resources might be better directed towards conditions that affect everyone rather than just those who choose to smoke.

Given these competing outcomes, Professor Kelly suggested an approach first introduced by the philosopher John Stuart Mill – that people should be free to make choices as long as they do not harm others.

In the case of smoking, this would mean permitting people to smoke as long as they are not affecting others when doing so, through passive smoking for example.

But in making such a judgement, are certain values being implicitly considered over others – such as the rights of the individual over those of the population?

Can spending personal budgets on football season tickets be justified?

The Citizen’s Council was then asked to examine the social values that need to be considered when balancing equity and efficiency in social care.

Social care encompasses a range of services such as day care, counselling, adoption and home care, and can be provided by a range of organisations. The Council looked at real-life examples which required a trade-off between equity and efficiency.

Among the scenarios discussed was the ethics of how individuals should use the resources allocated to them.

Personal budgets aim to provide service users with the ability to make informed choices about how they wish to spend resource on their social care. The Council examined a case from earlier this year, where a woman reportedly used her personal budget to purchase a Manchester United season ticket.

Some comment that this example highlights how personal budgets can be used inefficiently at a time when councils are facing increasing resource pressures.

However, others argue that the freedom and empowerment in being able to choose how one’s resources are used – especially if they increase one’s wellbeing – are on occasion worth the compromise in efficiency.

Prioritising budgets ‘is no simple task’

Given current resource constraints, how might health care commissioners ensure that they provided the best treatments to the people that need them most?

Paddy Storrie, Deputy Headmaster of St George’s School, and a former committee member for some of NICE’s technology appraisals, says social values will play in increasing role in health care.

As people are living longer, more people are contracting chronic conditions associated with old age such as cancer and dementia. Yet resourcing treatment for all who need it will test the system.

“NICE can help as it is the gateway for evidence-based cost and clinically effective treatments. But there are still questions that need to be considered, which cannot be captured through the evidence,” he says.

“For example, what particular needs does a person with a certain condition have? What are their healthcare priorities, what are the obstacles towards good health outcomes, and what personal circumstances might affect the fairness of their situation?”

“Given the current financial climate, ensuring everyone receives priority for the healthcare treatments they require is no simple task. As a commissioner if you can only resource one scenario, which would you choose?”

Summing up and next steps

To illustrate this, the Citizens Council was presented with two fictional scenarios, played out by actors.

The first scenario involved a 40-year-old woman who has an 18-year-old son. She is now requesting IVF treatment as she would like to have a child with her new partner.

The second featured a 30-year-old man who seeks a certain drug treatment for lung cancer. While effective in certain cases, the drug is very expensive and so not seen as cost-effective for the results it can achieve.

Having explored the issues of each case in detail, the Council was asked to consider the trade-offs between equity and efficiency and the social values that could be applied to each case. It was apparent that finding consensus was far from clear cut.

The Council then drew up a list of social values that could be applied to all three programmes, discussed some areas where considerations might differ between the programmes, and then examined whether there are special circumstances which might require a greater emphasis on either equity or efficiency.  

A report summarising the Council’s views will be available on the NICE website for public comment later this year, before the Council submits a report to the NICE Board setting out its findings.