Dear Alan et al.
 
New York is hardly Bushland. And, in any case, I live in the Socialist Republic of Columbia.
 
The emphasis on the individual increasingly pervades all aspects of society, and is closely related to postmodernism (the mention of which most health economists role their eyeballs at) - Edward Rosenthal has just had a book out on all this. The emphasis on the individual in health care, in the context of all this, may be inevitable, something that Rudolf Klein has said to me in the past. 
 
But what sort of equity should we be bothered about? And across whom? If we are really bothered about equity in health on a global scale, then all of our efforts probably ought to focus on the developing world. If we're bothered about equity of access to health care services, then health economic evaluation can potentially undermine that goal, because, in theory, it can lead us to spend all of our health care resources on, say, 10% of the population. I personally think that the health-related goals of health care services and the non-health care sector cannot be traded in any scientific way - health care is largely about trying to care for people who are already sick (which I think is very important, and we'll always have many people who are sick, irrespective of health promotion efforts), and the non-health care sector (e.g. education, incomes policy etc), such that they have health-related objectives at all, are about trying to prevent ill health in people who are currently healthy. Budgets for all the different sectors, so it seems to me, can only therefore be decided politically. 
 
On the subjects of academics musing - that's what they're supposed to do isn't it? Their effect is 'long-term' - could take decades. That's ok by me. If academics want an immediate strong policy influence, and have the confidence that they're right about anything, then in a democracy they should get themselves elected. But if we abandon the idea of democracy, then I'm very willing to serve as an appointed benevolent dictator.
 
Best, 
Adam 
   

________________________________

From: Maynard, A. [mailto:[log in to unmask]]
Sent: Mon 1/16/2006 10:18 AM
To: Oliver,AJ
Cc: [log in to unmask]
Subject: IPEH Report



Thanks for inviting this discussion Adam as you sit in the Big Apple in
Bushland!
 The nice paradox is the Government intervention in health markets was
initially largely driven by equity/access issues (Bismarck, Beveridge
etc) and this is still the case in "uncivilised" countries such as the
USA where we see Fuchs et al (NEJM 2005) advocating NHI again to tackle
the problem of the uninsured and underinsured Americans.
However now most developed systems are focused on expenditure
control/funding issues (the latter may have clear anti poor
distributional goals often) and waiting times issues, at the expense
both of equity and measuring and *managing health outcomes*. The
incentive structures in all systems ensure that equity in health care ,
let alone equity in health is left to academics to focus on!
For instance why should  NHS managers or doctors concern themselves with
equity when the former , at Government behest, are obsessed with process
targets and the latter are cushioned by ridiculous contracts that reward
process targets and on the job leisure?. Consequently I am always
surprised by Illsley-like comments as current incentives produce what we
see and what must be the goals of Government!
The goals of these incentives are sometimes poorly specified and
targeted (deliberately?) and when they are explicit, do we see mention
of equity in all its glorious forms, let alone rewards for aiding the
poor? No! If the UK "Labour" government was really interested in
reducing inequality and improving health they would not spend on the
NHS, as Trevor and I argued in 2002 (Maynard and Sheldon, Lancet, 360,
page 576). Rapid increased in health care expenditures produce some
process changes and generous rents for providers!.
What to do? Is interest in equity a thing that only liberal academics
can muse about, write about and cruise the conference halls discussing?
Societies with their increasing reluctance to act socially rather than
with an individual focus on choice and preferential access thru private
insurance means that equity may be further undermined e.g see the
debates in Canada and Australia; in the latter country the *Labour* 
opposition played the last election on the basis of keeping Howard's PHI
subsidies and Medicare in Alberta (the Texas of Canada with its oil and
diamonds) may be heading towards US "successes" in disadvantaging the poor!
How do you "sell" equity to politicians and electorates increasingly
dominated by the individual ethic so that incentives are aligned with
egalitarian distributional objectives? Collectivists appear to be a
dying breed e.g. what's the average age of the contributors to this
Nuffield volume?!
Can we change the incentive structure? If we don't academics can
continue to be erudite about equity issues and Adam can continue to
muse, Illsley like, later in life that what's constant, isn't daft, even
if we liberals do not share social values which give and enhance so such
inequality. *We can all feel good about identifying inequities and
specifying equity goals but have we changed in policy thinking let alone
policy making?* Some successes (e.g. needs based capitation formulae)
but too many blanks?
Examine your consciences oh! ye sinners! Go forth and really show you
love thy neighbour!

Oliver,AJ wrote:

>Hi
>
>A few years ago, a few of us put together a book (published by the Nuffield Trust) that tried to pull together different disciplinary perspectives and different topics on equity in health/health care (with each perspective written by eminent researchers in each area). The book came out of what we called the Issues Panel in Equity in Health (IPEH), and was really the first thing that HEN produced (Alan Williams and Raymond Illsley worked hard on trying to get it going).
>
>I've recently gone back and had a look at the book, and remembered how good I thought the end product was (but maybe I'm biased). I personally think it's still probably the best thing out there in terms of offering a broad cross-disciplinary approach on the issue. I've listed the main perspectives in the book below: there were also commentaries by John Wyn Owen (who also contributed a lot to establishing HEN), Simon Stevens, Trevor Sheldon and others.
>
>I remember Raymond Illsley commenting when we set up IPEH/HEN that he was curious whether any developments had occcured in the 50 years since he first worked on the issue. I wonder if people think that any further developments have occured in the last 5 years?
>
>Anyway, the IPEH report, if you're interested, is still downloadable (for free) from: http://www.ukhen.org/publications.htm
>
> 
>-David Blane: Where have we got to? Where should we go?
>-Raanan Gillon: Value judgments about equity in health
>-Roy Carr-Hill and Alan Williams: Measurement issues concerning equity in health
>-Roy Carr-Hill: Equity in health: a note on resource allocation
>-Mark McCarthy: Causes and contributions of public health
>-Julian Le Grand: What kind of health inequality?
>-Iona Heath: The role of the NHS in tackling health inequalities
>-Rudolf Klein: Inequalities: setting targets?
>-Robert Dingwall and Paul Martin: Implications of genetic advances for equity in health
>-Raymond Illsley: Policy options
>-Alan Williams: Equity and cost-effectiveness: a short note
>-Mark Petticrew and Sally Macintyre: What do we know about the effectiveness, and cost-effectiveness of measures to reduce inequalities in health?
> 
>
>
> 
>