Ray Robinson

Health technology assessment and its influence on health-care priority setting

In this article, we review the development of health technology assessment (HTA) in England and Wales, France, The Netherlands, and Sweden, and we summarize the reaction to these developments from a variety of different disciplinary and stakeholder perspectives (political science, sociology, economics, ethics, public health, general practice, clinical medicine, patients, and the pharmaceutical industry). We conclude that translating HTA into policy is a highly complex business and that, despite the growth of HTA over the past two decades, its influence on policy making, and its perceived relevance for people from a broad range of different perspectives, remains marginal.

Primary care trusts

Premature reorganisation, with mergers, may be harmful

The Interplay between Economic and Political Logics: Path Dependency in Health Care in England

The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.

Limits to rationality: economics, economists and priority setting

This paper investigates why economic approaches to priority setting have had only limited impact in practice. It argues that obstacles to the take-up of the economic approach centre on (1) limitations in the theory and practice of economic evaluations, and (2) the nature of the wider context within which decisions on priority setting take place. On the first point, it argues that, despite advances in research methods, there is still debate about the theoretical basis of measures typically used in economic evaluations, such as QALYs, and that much of the extant empirical data is of questionable quality. On the second point, it maintains that politicians, health care professionals and local people attach importance to other factors besides allocative efficiency. If economic approaches are to have more impact in the future, it argues that health economists need to adopt a wider research agenda, focusing on public sector decision-making and, in particular, the incentives and constraints governing the use of economic data in different types of health care organisation.

NHS foundation trusts

The rudiments of the governments current strategy for the NHS are set out in the white paper Delivering the NHS Plan. 1 This contains a commitment to maintaining a general tax based system, universally available and free at the point of use, and also sets out an ambitious agenda for supply side reform. A central component of this agenda is the creation of a whole raft of new institutions designed to set, monitor, and ensure national service standards—for example, the newly created Commission for Healthcare Audit and Inspection. At the same time, selected local organisations are to be given greater freedom and devolution of decision making power. This is referred to as a process of earned autonomy. The concept of earned autonomy represents an attempt to combine some of the advantages believed to flow from devolved decision making (including flexibility, innovation, and local responsiveness) with the retention of a commitment to NHS principles and national standards. One of the first vehicles for developing this approach …

Gold for the NHS

The chancellors budget statement sets out plans for unprecedented rates of growth in NHS spending over the medium term. Responding to the Wanless review teams challenge on the long term funding needs of the NHS,1 the chancellors special, five year settlement for the NHS will mean an extra 7.4% real terms expenditure each year over the period 2003-4 to 2007-8. This will increase the NHS budget from £65bn (

Managed care in the United States: a dilemma for evidence-based policy?

94bn; ![Graphic][1] 106bn) this year to £105bn after five years (allowing for inflation) and represent a rise in the share of gross domestic product spent on health care from 7.7% to 9.4%. Some idea of the scale of these increases in expenditure can be gauged from the fact that over the period 1954-2000 annual increases in real expenditure on the NHS averaged 3.7%. If plans are realised, the next five years will double this rate. For those who have lamented NHS underfunding over the past 20 years, this is unadulterated good news. … [1]: /embed/inline-graphic-1.gif