1. Themes Emerging from Country and Related Presentations Notes from session 1545 – 1730 Thursday 17 February 2011 Albert Weale

2. Transparency All systems have many actors involved in making decisions that affect priorities, some are explicit and some are background (eg who sets bridge safety standards?). How are decisions made? Korea case of not being clear how new drugs are recommended. Some decisions made through bargaining between industry and those setting expenditure priorities. Can have transparency on process but not on appraisal, as in German example. Transparency versus negotiation.

3. Accountability French experience of greater accountability to parliament through tighter monitoring. Complicated sets of actors, with different decision making processes. Different sorts of accountability to different actors, eg costs and benefits. We should not neglect non-decisions (and who benefits from non-decisions).

4. Participation How are stakeholder representatives selected? Are there particular groups (patients?) who are key stakeholders? France increasing patient representation. Thailand allows stakeholders to propose balance of preventive/curative, picking priorities from list. Role of professional associations in recommending members for assessment committees, compare Korea. Also the self-governing principle in the German SHI system. Who makes up the crucial institution? Professional public servants/volunteers/others? Is there a difference between starting as policy planners with cost- effectiveness and forming priorities through deliberative participation? Note: our political science on the comparative functioning of different methods of participation is weak. Citizens, patients, stakeholders, providers.

5. Clinical Effectiveness/Evidence Who generates the evidence? How is evidence brought together? Decision strategies. Information comes in all the time. Reassessing risks. How to handle statistical information. World of risk or uncertainty?

6. Cost Effectiveness Value or vehicle? NICE legally required to look at this, also Korea drugs assessment. Implications of such a legal requirement? Use of threshold approach. Moving to value- based pricing and efficiency frontier approach. Health analysis across diseases or not. High value/high intensity care is not necessarily quality care. Cost effectiveness of displaced care.

7. Equity/Justice Different types of scheme for different people. Role of HTA in helping to reduce disparities. Choice of prioritisation criteria. Broader context of social justice, as exemplified in fixed budget systems. Open ended system. Due process aspects, and the time taken to do appraisal, model of early benefit assessment. Inter-generational issues when care becomes important. Sustainable solidarity: duty to keep the system viable for the future. Note also the issue of discounting.

8. Solidarity China’s distinction of social pooling and individual account. Cost-sharing is an issue in all systems. Basis is important, eg cost-sharing implications for high cost patients. Differential packages.

9. Autonomy Use of co-payment regimes to allow greater autonomy? Moving down the tier. Using providers outside of ACOs, exit and voice.

10. Social Values Economic and social. Economics as good way of revealing social values: (process modelling). But what is economic analysis? Financial cost/opportunity as alternative readings. Is the problem how to balance equity and cost assessment? Or is it how to structure prudently finance adequate health care?

11. Institutions and Levels of Decision Making All these decisions take place in specific institutions. Reconciling the macro and the micro. National and local – post-code rationing debate in UK. ACOs seem to face same problems by and large as national systems, but the ‘gaming’ issue is distinct. Exit, voice and loyalty? EU and the right to cross-border care. Devolved decision making and its implication for accountability. Back to the future.

12. Practical Reasoning Requirement for empirical evidence. Scoping the decision making process, in values and empirical evidence. Attempts to systematise the decision making process (Thailand). NICE ICER is a ‘rule and exemption’ approach. Unhelpful distinction of scientific and other. Scope of evidence needed for social care interventions. Looking at decisions made in other places – learning from comparative evidence. Avoiding a mechanistic approach.

13. Defining Benefit Discussions about the value of innovation. Assessing community benefit from a range of interventions – feeds into issues of evidence and the difficulty of getting synoptic evidence. Value-based purchasing of drugs. Should not equate costly care with quality care. Health care services or priority setting for public action.

14. Measurement/Operationalisation Data reduction is always involved. If we are interested in equity, how do we know that we are achieving what we aim for? Measuring community benefit, adding marginal value.

15. Research Question Keep institutions in mind. What would policy makers find useful to help them with their decisions? What would you like to know about other systems? What are your key challenges? If there is sufficient convergence on value matrix, is the question then HOW?