Table 2

Value elements related to wider impacts of healthcare

Value elementRationaleImplicationsIssues
RarityMany authorities provide special treatment for rare conditions, orphan drugs etc. on the basis of equity or commercial considerations.12 13 Higher willingness-to-pay for healthcare for certain rare conditions, in preference to common conditions.This is controversial and does not appear to be in keeping with societal preferences.36
Wider societal impactPoor health may impair a person’s capacity to engage with society, such as through paid or unpaid employment or providing care for others.Added value may be attributed to treatments and patient groups that are more likely to have greater benefits to societyThere are ethical issues around measures that would value people based on some measure of ‘productivity’. NICE suggested using a ‘societal shortfall approach’18 but subsequently rejected the proposal.14
Equality (non-discrimination) and equity of accessEquality is often governed by antidiscrimination regulation. ‘Postcode prescribing’ was one of the drivers for the development of NICE.64 If a treatment is more cost-effective for a subgroup of population then trade-offs are required between equality and cost-effectivenessEthnicity, age and gender may be important risk factors for disease and the outcome of treatment and may, thus, be determinants of benefit.
Addressing healthcare inequalitiesThis is a founding principal of the NHS and a stated government objective.19 Resources may need to be targeted at disadvantaged populations or those with higher burden of disease.May require positive discrimination and, thus, be at odds with equity and cost-effectiveness considerations.
Innovation/scientific spilloverIncremental development of science means new products may underpin further products.6 Value of new product is distributed between the steps in the chain of developmentWould also imply a reduced value to account for prior developments, such as the publicly funded human genome project.20
Fear of contagion/risk of contagionFear of, or the risk of contagion may require public health measures or influence behaviour in a way that has significant health and economic impacts, beyond the direct effects of the disease on individual health.6 Allocation of resources to planning for potential epidemics, over and above that justified by the likely health consequences.Difficult to quantify the risks related to an unknown future infective outbreak.
  • NHS, National Health Service; NICE, National Institute for Health and Care Excellence.