Equity versus efficiency: a dilemma for the NHS

Concerns about equitable provision and financing of health care have characterised the NHS since its foundation. Evidence of persisting and, in some cases, widening health inequalities, gathered since the publication of the Black report,1 has progressively raised equity to a high rank among health policy objectives.2 Though the general aim of reducing health inequalities appears uncontroversial, the practical notions of equity that should inform policy and the ways in which these should be implemented are far from clear. Even more importantly, there is no consensus on how to deal with policies that may cause a conflict between the goals of equity and efficiency—that is, those that may improve efficiency while increasing health inequalities or improve fairness while decreasing efficiency. The equity versus efficiency dilemma3 has been virtually ignored in the political debate, often leading to inconsistent judgments in the development of health policies. In a report recently published by the NHS Health Technology Assessment programme4 we examined examples of the equity-efficiency dilemma that the NHS …