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    Health inequalities modular update of NICE Health Technology Evaluations: the manual (PMG36)

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    Table 1. Proposed new content

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    Suggested section

    Evidence of health inequalities

    3.3.28 Quantitative evidence on health inequalities for the UK population can be provided to help committees understand the scale of health inequalities relevant to eligible populations in NICE's guidance programmes.  

    3.3.29 When a company or stakeholder believes there are health inequalities that are relevant to the eligible population, quantitative evidence can be provided. Supporting materials can include:  

    • descriptive statistics on disease burden  

    • information on social or structural barriers to accessing care or participating in research faced by specific populations.

    3.3.30 Important context on health inequalities can be provided by data that shows:

    • differences in health outcomes between social groups in the eligible population

    • that specific conditions are more common in already disadvantaged groups. 

    3.3 Types of evidence

    Impact on health inequalities

    4.12.1 The benefits and costs of new health technologies may not be equally distributed across social groups, which can impact health inequalities. Distributional cost-effectiveness analysis (DCEA) is an economic evaluation framework for synthesising evidence on health inequalities. It determines how costs and benefits vary across population groups. It can be used to show the potential impact of a new technology on health inequalities and specifically the health inequality gap in the general population.

    4.12.2 DCEA should only be included in an economic evaluation when there is clear evidence of a significant burden of health inequalities in the eligible population. This should be supported by quantitative evidence (see technology evaluation methods support document on health inequalities).

    4.12.3 DCEA should only be used as supporting evidence of the potential for a technology to impact health inequalities. Cost-effectiveness results by subgroups based on social characteristics should not be part of the base-case analysis or presented as non-reference case scenarios.

    4.12.4 NICE's technology appraisals and highly specialised technologies recommendations do not give guidance on service delivery or to support implementation for disadvantaged groups. Committees can only recommend technologies as options for use in the NHS. Differences in uptake may determine health inequality impacts and be relevant to a committee's deliberations, but they cannot be addressed by a committee's recommendations.

    4.12.5 Committees should be aware of the remit of their guidance programme and consider how any variations in modelled uptake would be addressed by the new technology.

    4.12.6 The results of the DCEA should not weight the costs or benefits of a technology differently based on the recipients' social characteristics.

    4.12.7 Health inequalities issues may be relevant to a range of technologies and diseases. So, it is important that DCEAs that are done to support decision making are consistent. The key components of DCEA and NICE's preferred methods are summarised in technology evaluation methods support document on health inequalities . Other approaches can be presented if appropriate, but deviations from the methods specified must be clearly justified and supported by evidence.

    4.12 (new section in Economic Evaluation chapter)

    Structured decision making: health inequalities

    6.2.36 When there is robust evidence showing the technology substantially reduces or increases health inequalities, the committee will consider how this could impact its decision about whether the technology is an effective use of NHS resources (see section 6.2.38-6.2.39 below).

    6.2.37 Consideration of the health inequality impacts of a technology is separate from NICE's legal obligations on equality and human rights, including under the Equality Act 2010.

    6.2.38 When considering the relevance of health inequality impacts on the value of the technology, the committee will consider the level of uncertainty associated with the health inequality analysis. When there is robust evidence specific to disease or condition that uncertainty or potential biases in the evidence on health inequality impacts are the result of structural or social barriers, the committee may accept a higher level of uncertainty in the health inequality analysis.

    6.2.39 When considering the relevance of health inequality impacts on the value of the technology, the committee can apply flexibility to the range normally considered a cost-effective use of NHS resources, but it must consider the effects of healthcare displacement and opportunity cost before doing so and provide a rationale for stakeholders. This flexibility should only be applied when the size of the health inequality impacts of a technology are substantial. It should not be used to justify restricting the population of interest to a subgroup based on cost effectiveness (see section 4.9). The committee will not use quantitative evidence on health inequality impacts to make optimised recommendations for subgroups based on social characteristics.

    6.2 (new section in Assessing the evidence)