Theory versus Practice:
Discussing the Governance of Health Technology Assessment Systems
M any governments around the world have introduced a decision making process in healthcare known as healthcare technology assessment or HTA, which helps them decide which medicines and treatments to fund from limited public health budgets. This article looks at the theory of HTA versus the practice of how HTA is conducted in the real world. It argues that, if HTA is here to stay, we need to move towards a gold standard of HTA policymaking with some clear principles including transparency, flexibility and consideration of the wider funding climate within which HTA decision are made.
Theory
The creation of welfare states throughout Europe and beyond has led in many cases to a system where national governments are the consumers of healthcare, purchasing health technologies on behalf of their citizens.
As a consequence of this arrangement, many national healthcare decision makers feel the need to rely on a cost-effective analysis of new and emerging health technologies, the results of which they use to decide whether to provide treatments to the patients that fund the whole system. This is known as Health Technology Assessment (HTA).
HTA is the focus of a Stockholm Network research series that aims to highlight the gap between the theory and practice of HTA, as well comparing the extent to which the HTA process is applied by separate national agencies.
The latest paper in this series - Theory versus Practice: Discussing the Governance of Health Technology Assessment Systems – concentrates on the conduct of HTA in four key countries – Australia, Canada, Germany and the United Kingdom – describing the key commonalities that exist between each system, but also underlining their significant differences.
This comparative study allows for the understanding of different practices of HTA that could contribute towards promoting a “gold standard” for conducting HTA.
Practice
There is no single model for a HTA system, but rather a number of different arrangements that attempt to serve the same purpose. Indeed, the rationale for HTA and the overall process used to conduct it in the four countries covered shows a wide degree of consensus.
Yet, the countries begin to differ more prominently when looking at their individual systems of HTA, reflecting as they do the values and funding of the wider healthcare system within which the HTA agencies perform.
Therefore, as healthcare services continue to be provided in a variety of ways, so too will HTA.
In addition, whilst there may be a number of operational comments that can be made about the way in which HTA is conducted, some criticisms that are made against particular HTA decisions could be more appropriately aimed at the national health system of a particular country rather than the HTA body per se.
“Topping-up”
To give an example we may consider the recent “top-up” debate which has caused some controversy in the UK and has led to a significant amount of criticism aimed at NICE.
The “top up” debate opposed a practice that was happening in the NHS, which was denying patients who were paying for their own medicines privately (usually for cancer) from having access to publicly-funded care for the same illness. In this debate, NICE was seen as depriving patients of life-saving drugs as their decision to place a health technology on a negative list was directly prohibiting patients from having those treatments.
In this and indeed many similar examples, the problem stems mostly from the healthcare system itself and, in this case, the NHS’s inability to accommodate a topping-up system.
Thus, it is very often the case that a healthcare technology assessment body is only as good as its governing healthcare system.
HTA’s virtues
Although this may be true, there are certainly a number of lessons that can be learnt about the conduct of HTA and in particular there are certain “virtues” that a HTA body should work towards, regardless of the health system that it performs within.
One such “virtue” is flexibility and the ability to appreciate local needs and individual concerns. Whilst some can see a particular benefit from having an uncompromising system that focuses on a rigid idea of cost-effectiveness, it is valuable for a system to be able to shape its recommendations around the needs of the population.
The notion of a negative list, which many systems use, provides an indication of how inflexible some systems can be. It would be much more useful if HTA recommendations were used as a basis for trying to find ways of providing more expensive treatments.
Rather than a HTA agency declaring that “this treatment is not cost-effective”, it would be better if it said “this treatment would be cost effective if…” and outlined circumstances where a technology could be allocated.
Indeed, this allows for more flexible reimbursement arrangements which could detail that technologies could be allocated only to certain groups or only in certain circumstances.
national health systems need to be able to offer patients a variety of means of paying for healthcare treatments
Furthermore, national health systems need to be able to offer patients a variety of means of paying for healthcare treatments.
If a system is structured so that some patients can top-up their care, or if there is a helpful co-payments system, then the recommendations made by HTA agencies will not necessarily end in the denial of treatment for patients.
HTA systems should also focus on becoming as accessible as possible, allowing their decisions and decision-making processes to be open for all to see. Transparency does not just provide the reassurance that a decision has been reached fairly and sensibly, it also allows for a more comprehensive and effective recommendation.
By including health professionals, industry representations, lay people and patient groups, an agency can ensure that the assessments it makes are relevant and will guarantee a smoother rolling out of its recommendations.
Finally, it cannot be forgotten that HTA systems form part of the wider health system they conduct their assessments within. In other words, one cannot look at the HTA system (or its decisions) as being isolated from the overall heath system in a given country.
Accordingly, the policy actions and budgetary decisions that take place in the wider context of the national health system are likely to have a significant effect on the manner in which HTA decisions affect the ability of patients to gain access to new healthcare technologies.
Decisions-makers and politicians cannot just hide under the "scientific veil" of HTA bodies. Rather both politicians and the public need to examine the HTA system with a more critical eye – to endorse its main points of strength but also to identify its limitations and weaknesses and to address them accordingly.
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