Value-based healthcare in the UK: A system of trial and error

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Value-based healthcare in the UK
A system of trial and error
A report from The Economist Intelligence Unit

1© The Economist Intelligence Unit Limited 2016
Value-based healthcare in the UK A system of trial and error
Contents
About this report 2
Introduction3
Chapter 1: Evolution of a centralised system and the NICE model 4
Chapter 2: Experimentation and identifying gaps 7
Conclusion12

2 © The Economist Intelligence Unit Limited 2016
Value-based healthcare in the UK: A system of trial and error is
an Economist Intelligence Unit (EIU) report, commissioned
by Gilead Sciences. Value-based healthcare looks at health
outcomes of treatment relative to cost. In this particular report
The EIU examines the structure of UK healthcare delivery, the
unique model used by its health technology assessment (HTA)
agencies, and its history of experimentation in value-based
pricing.
In December 2015 and January 2016 The EIU conducted four
interviews with experts on value-based healthcare in the UK.
The insights from these in-depth interviews appear throughout
the report. The EIU would like to thank the following
individuals (listed alphabetically) for sharing their insight and
experience:
l Hugh Alderwick, senior policy adviser to the chief executive,
The King’s Fund
l Kalipso Chalkidou, founding director, NICE International
l Karl Claxton, senior research fellow, Centre for Health
Economics, University of York
l Matthew Cripps, NHS England’s national director, RightCare
The EIU bears sole responsibility for the content of this
report. The findings and views expressed in the report do not
necessarily reflect the views of the sponsor. Andrea Chipman
was the author of the report, and Martin Koehring was the
editor.
February 2016
About this
report

Introduction
The UK has long been in the vanguard among
European countries looking to expand their
use of value-based healthcare. Many European
policymakers have looked to the UK’s National
Institute for Health and Care Excellence (NICE) as
a model; NICE provides evidence-based guidance
about the cost-effectiveness of new treatments,
among other responsibilities.
Its National Health Service (NHS), in England
in particular, has experimented in recent years
with various pay-for-performance models, as
well as efforts to identify and eliminate localised
variations of care and treatment pathways that
are seen to be ineffective.
Yet years of structural healthcare reforms have
both impacted the morale of providers and left
a more fragmented system, making it unclear to
what extent the country can actually increase
value for money, even if it can identify that value.
“From whose perspective is value being defined?
Inevitably, it’s from the perspective of payers
as budgets are getting tighter,” says Kalipso
Chalkidou, the founding director of NICE
International, the international arm of NICE UK.
“Comparing [innovative treatment] to the next
best thing currently available makes it easier to
contain costs and make sure taxpayer money is
being invested wisely.”

Chapter 1: Evolution of a centralised
system and the NICE model1
The NHS, founded in 1948 as one of the earliest
universal healthcare systems, is funded by
general taxation, including national insurance
contributions. It is arguably a more centralised
system than those of its European neighbours.
The system is both publicly financed and operated
primarily through the public sector, although
market reforms have steadily introduced private
providers within England over the last few
decades.1
In the wake of the devolution of healthcare
in 1999, NHS England accelerated its internal
market, while Northern Ireland, Scotland and
Wales have refrained from instituting a similar
split between purchasers and providers.
Structural reform
In England, a ministerial department—the
Department of Health—provides strategic
leadership and funding for both healthcare
and social care. NHS England, formerly known
as the NHS Commissioning Board, acts as
an independent body at arm’s length to the
government, offering national leadership for
improving outcomes and driving up the quality of
care.
NHS England directly commissions primary care
and highly specialised services. It also oversees
so-called clinical commissioning groups (CCGs)
and allocates resources to them; CCGs work
together in general practices to plan, design
and buy local health services in England, such
as planned hospital care, rehabilitative care,
urgent and emergency care, most community
health services, and mental health and learning-
disability services.
Since devolution the NHS has continued to be the
subject of periodic structural reforms, the most
recent of which was the Health and Social Care
Act of 2012. Designed to put clinicians in charge
of commissioning healthcare services, the Act
replaced 152 primary care trusts and specialised
commissioning groups with 211 CCGs.
“CCGs are still relatively new, so it’s difficult to
assess their impact in comparison with other
forms of commissioning,” says Hugh Alderwick,
a senior policy adviser to Chris Ham, chief
executive of The King’s Fund, a UK healthcare
think-tank. “Some are arguing, however, that
CCGs need to take a more strategic role rather
than being involved in multiple transactional
relationships with providers, and that they
should be more focused on defining and
monitoring system outcomes.”
In recent years the health service has also been
subject to an extended drive for efficiency, the
Quality Innovation Productivity and Prevention
1
Nuffield Trust and Institute
for Fiscal Studies, Public
payment and private
provision: The changing
landscape of health care
in the 2000s, May 2013, p.
11. Available at: http://
www.nuffieldtrust.org.
uk/sites/files/nuffield/
publication/130522_public-
payment-and-private-
provision.pdf

(QIPP) initiative. The programme, which was set
up with the aim of making £20bn (US$29bn) of
savings by 2014-15 and even more beyond that,
has put NHS trusts under severe pressure and has
been blamed for high-profile stories involving
poor patient care. A King’s Fund study of six NHS
trusts found that all were “pessimistic about
their ability to continue to make ends meet and
improve quality in the next few years.”2
NICE at the heart of decision-making
structure
The structure of health technology appraisal in
the UK comprises three separate agencies with
responsibility for the authorisation, regulation,
classification and surveillance of pharmaceutical
products and medical devices: the Department of
Health Medicines, Pharmacy and Industry Group
(MPIG); NICE; and the National Institute for
Health Research (NIHR).
The MPIG regulates the reimbursement and
pricing schemes and sets the NHS list price.
Prices of branded prescription medicines
are controlled under the Pharmaceutical
Price Regulation Scheme (PPRS), a voluntary
agreement between the Department of Health
and the Association of the British Pharmaceutical
Industry (ABPI) that is negotiated by both
parties on behalf of companies supplying in-
patent branded medicines to the NHS, which
account for some 70% of NHS spending on
drugs.3
Companies that are not party to the
PPRS are automatically subject to a statutory
scheme that imposes a list-price cut of 15% on
all products manufactured by the companies it
covers, although the statutory scheme covers
only around 6% of medicines by value.4
The PPRS has been in place since 1957 and is
continually updated, with the current five-year
agreement due to expire in 2018. The agreement
is meant to balance the need for the government
to achieve reasonable prices for medicines
prescribed within the NHS with the role the
industry plays as an employer and investor in
research and development (RD) in the UK.5
The Drug Tariff sets reimbursement prices for
generic medicines. Generics have a high market
share in the UK, accounting for 67% of the
market.6
The most influential body in the appraisals
process is NICE, which was established in 1999
and has two principal roles. NICE technology
appraisals provide recommendations relating to
the approval of prescription medicines, while the
agency also provides evidence-based guidelines
on a range of topics—from preventing and
managing specific conditions to planning broader
services and interventions to improve the health
of communities.
NICE operates according to a cost-effectiveness
threshold measured in quality-adjusted life
years (QALYs), in which it generally refuses
to recommend medicines that cost more than
£20,000 to £30,000 per QALY. In the case of
patients close to the end of life this threshold
can sometimes be extended to £50,000 per QALY.
The NHS, by law, must fund medicines that NICE
approves within 90 days of a published decision.
Those medicines that NICE rejects or has not
yet approved tend not to be funded. However,
recently there have been questions both about
whether the NHS is paying too much for new
drugs and how to increase the number of patients
able to access the most innovative treatments.
Finally, the NIHR, established in 2006 with
funding from the Department of Health, manages
the Health Technology Assessment (HTA)
programme and the NIHR Technology Assessment
Reviews (TARs), with nine research teams
contracted to respond to the needs of NICE and
other policymakers with independent research.
The UK has no separate reimbursement and
pricing mechanisms, and the Department of
Health grants full reimbursement and approves
pricing for most new prescription medicines for
the outpatient and inpatient sectors once either
the European Medicines Agency (EMA) or the
Medicines and Healthcare products Regulatory
2
The Kings Fund, The NHS
productivity challenge:
Experience from the front
line, May 2014, p. 5.
3
Raftery, J, “Value based
pricing: can it work?”, BMJ,
October 2013.
4
Department of Health,
Consultation on Changes
to the Statutory Scheme
to Control the Prices of
Branded Health Service
Medicines: Consultation on
Changes to the Regulations
Underpinning the Statutory
Scheme, September 2015.
Available at: https://
www.gov.uk/government/
uploads/system/uploads/
attachment_data/
file/459219/stat_scheme_
consultation_2015.pdf
5
Association of the British
Pharmaceutical Industry,
Understanding the 2014
Pharmaceutical Price
Regulation Scheme, 2014,
p. 1. Available at: http://
www.abpi.org.uk/our-work/
policy-parliamentary/
Documents/understanding_
pprs2014.pdf
6
British Generic
Manufacturers Association.
Available at: http://www.
britishgenerics.co.uk/

Agency (MHRA) has granted them market
authorisation and NICE or NHS England has
approved their use. NHS England has a growing
role in assessing specialist medicines in cases
where NICE does not evaluate them.
All medicines that are eligible to be prescribed
on the NHS receive full reimbursement, with the
exception of those on negative or restrictive
lists; hospital pharmaceutical and therapeutics
committees agree on formularies of medicines
that can be prescribed in hospitals, with some
exceptions possible, and pharmaceuticals
are covered as part of hospital care. Hospital
pharmacists work with commissioning
organisations to decide which medicines are
available in hospitals locally, unless national
guidance overrules this.
Outpatients pay a standard, fixed prescription
charge of £8.20 per item, with exemptions
based on age, medical condition or income,
and 90% of prescription items are dispensed in
the community free of charge. In some cases,
hospitals may be able to purchase medicines
under contract at a discount to the NHS list price.

Although the UK has a comprehensive system for
measuring cost-effectiveness of new drugs and
technologies by NICE, the definition of value can
still be a moving target. Initiatives over the past
five years have tried to understand and clarify
how a new form of value-based pricing could be
introduced for the assessment of certain drugs,
with mixed results.
Mr Alderwick of the King’s Fund notes that UK
policymakers have, over past decades, introduced
a range of pay-for-performance (P4P) measures
in different parts of the NHS, including the
Quality and Outcomes Framework (QOF) in
primary care and Best Practice Tariffs (BPTs) in
secondary care, both of which aim to incentivise
the use of evidence-based methods and, where
possible, reduce the use of unnecessary costly
interventions.
A separate approach has looked to identify
variations in care delivery and ways of altering
care pathways to eliminate these inequities.
Finally, there have been efforts to modify NICE’s
value threshold to take into account a wider
range of factors to inform decisions, a process
that has experienced fits and starts in recent
years.
Introducing incentives for providers
The QOF is an annual reward and incentives
programme which assesses the results of
general practitioner (GP) surgeries in England.
Introduced as part of the GP contract in 2004, it
provides incentives for GP practices for providing
quality care and standardising improvements
in primary-care delivery for chronic diseases
such as diabetes and asthma, public-health
challenges such as smoking and obesity, and the
implementation of preventive measures such as
blood-pressure checks.
While both England and Scotland have similar
aims in incentivising better integration of care,
Scotland has more recently created a single
outcome framework for both healthcare and
social care services, distinguishing its approach
from the NHS in England, Mr Alderwick observes.
In 2009 the government introduced the
Commissioning for Quality and Innovation
(CQUIN) initiative, which enabled healthcare
commissioners to reward excellence in care by
linking part of English healthcare providers’
income to the achievement of local quality
and improvement goals. CQUIN includes both
national and local targets.
In an addendum to these measures, the coalition
government that was in place between 2010 to
2015 introduced BPTs, defined as care that is
both clinical and cost-effective; the tariffs were
Chapter 2: Experimentation and
identifying gaps2

designed to help the NHS deliver productivity
gains and improve quality by reducing
unexplained variations. The system included
individual tariffs for each service area.7
Yet a clear assessment of the success of these P4P
measurements has been challenging. “Evidence
suggests that some pay-for-performance
schemes have improved processes and quality
of care. But evidence of their impact on
outcomes is limited. Evaluations of the success
of payment systems in incentivising outcomes
is scarce,” Mr Alderwick says. “More recently,
local commissioners have begun to try to
construct new contracts for their local providers,
covering payments for the care of a defined local
population, with a proportion of these payments
linked to the delivery of agreed outcomes of care.
In the NHS it’s too early to assess the impact of
those newer approaches.
A 2014 report from an independent health
charity, the Nuffield Trust, found that while
a move from block budgets to activity-based
payments had improved provider productivity in
acute care, block contracts remained the most
common payment mechanism in community
health.8
In addition, the report found that
introducing incentives across services was doing
little to shift care out of the hospital setting.
Instead, activity-based payments in acute care
encouraged further care in hospitals, while block
budgets in community services and capitated
budgets in primary care provided little incentive
to increase care in these sectors or make it more
efficient.
With regard to the specific incentives the
government had introduced, the Nuffield
Trust report concluded that while the QOF and
BPTs supported a role for the payment system
in improving quality, CQUIN had been less
successful.
To be sure, notes Mr Alderwick, there have been
some examples where making contracts like
these has not been successful in practice, and
much depends on implementation and the ability
of multidisciplinary teams to work together to
adapt care-delivery models. In December 2015
UnitingCare, a consortium of Cambridgeshire and
Peterborough NHS Foundation Trust (CPFT) with
Cambridge University Hospitals NHS Foundation
Trust, announced that it would end an £800m
contract to provide care to the elderly after just
eight months because the care was “no longer
financially sustainable”. Union representatives
said the consortium was unable to make
financial cost savings on the contract, which
was ultimately transferred to the Cambridge and
Peterborough CCG.9
“The relative success of these initiatives is down
to local implementation, and ultimately the
engagement of clinicians in actually changing
how care is delivered on the ground is going to
determine how well you make change happen,”
Mr Alderwick adds.
Addressing inequities in healthcare
In addition to seeking quality and productivity
improvements through financial incentives,
healthcare reformers in England, in particular,
have also sought to address sharp variations in
healthcare outcomes across the country.
At a recent conference at Oxford University
Professor Sir Muir Gray, the director of Better
Value Healthcare and an adviser to Public Health
England (an executive agency of the Department
of Health), defined the causes of unwarranted
regional variation as threefold: 1) patient
harm from overdiagnosis and overtreatment,
even when treatment is of a high quality (eg
chemotherapy in the last week of life, antibiotics
or deaths in hospital); 2) inequities in the
healthcare system owing to the underuse of high-
value healthcare services by certain social groups
(such as hip replacement surgery); and 3) waste,
including any treatments that do not add value
for patients or could provide more value if used
for different patient groups.10
7
Department of Health,
“Update to Best Practice
Tariffs”, December 13th
2011. Available at: https://
www.gov.uk/government/
news/update-to-best-
practice-tariffs
9
“Cambridgeshire’s £800m
NHS out-sourcing contract
ends,” BBC News, December
3rd 2015. Available at:
http://www.bbc.co.uk/
news/uk-england-
cambridgeshire-35000421
8
Nuffield Trust, The NHS
payment system: evolving
policy and emerging
evidence, 2014. Available at:
http://www.nuffieldtrust.
org.uk/sites/files/nuffield/
publication/140220_nhs_
payment_research_report.
pdf
10
Sir Muir Gray,
presentation at “Hellish
Decisions in Healthcare
2015” Conference, held at
Oxford University, December
7th-9th 2015.

Reassessing healthcare systems within this
context involves what Sir Muir referred to as the
“triple-value framework”, consisting of allocative
value, which is determined by how assets are
distributed to different population groups;
technical value, involving the way in which
resources are used for all people in need in each
sub-group; and personal value, determined by
how accurately decisions relate to the values of
each individual.11
One programme that has attempted to address
inequities in healthcare in England within this
value framework is the NHS RightCare programme
that was launched in 2009-10, according to
Professor Matthew Cripps, NHS England’s
national director of RightCare.
“If the end is value, then the means to achieve
it is getting rid of unwarranted variation,”
Professor Cripps notes. “You can’t ignore finance-
based decisions, but you need to understand
how to reach the finance-based objectives of the
system in ways that support value.” He describes
the programme as a “bespoke improvement
methodology designed from scratch that could
engage the clinical and management sides
equally in partnership.”
The programme’s first phase draws upon an
evaluation of where the largest areas of variation
exist, whether in diabetes, asthma or other
health issues categorised as priorities by local
health authorities. This evaluation, published in
“Commissioning for Value” packs for every health
economy in England, defines phase two, which
involves identifying what needs to be changed
to transform sub-optimal patient outcomes into
optimal ones. The second phase highlights the
parts of the clinical pathway that are not up to
scratch.
“You will have the design of what we should
be doing and the reality of what we are doing;
compare the two, and the difference is the thing
you need to change to make [the pathway]
optimal,” Professor Cripps explains.
Finally, the third phase of the process starts with
the diagnosis and aims to reach consensus across
the system about how to change practices. “We
didn’t explain it to policymakers as a hypothetical
thing; we got individual health economies to
adopt the approach and demonstrate that it
works,” he adds. “We convinced them by creating
proof of concept.”
Policymakers from countries ranging from
Denmark to Australia have shown interest in the
concept, although by nature the programme
requires that policymakers cede autonomy to
local decision-makers to determine what to focus
on. Also available and published with Public
Health England are a series of “NHS Atlases
of Variation in Healthcare in England”. These
include six specific reports for conditions ranging
from diabetes to kidney disease. The atlases
illustrate the three phases of the RightCare
process through individual case studies.12
Value-based pricing in pharmaceuticals
Given the steadily rising cost of the most
innovative medicines and technologies, it is
unsurprising that one of the most controversial
areas of UK healthcare policy has continued to be
the effort to define more clearly value for money
in the area of pharmaceuticals.
Government proposals to move towards value-
based pricing, first introduced in 2007 by the
Office of Fair Trading (a not-for-profit consumer-
protection organisation dissolved in 2014),
were made more explicit in the 2009 PPRS. In
2013 NICE adopted new terms of reference for
implementing value-based assessments, which
included a broader definition of value that
incorporated both the burden of illness and wider
societal benefits in its assessments.
The new approach, which was initially due to be
implemented in August 2014, was designed to
make cost-benefit decisions more transparent,
consistent and predictable, according to the
ABPI.
11
Ibid.
12
NHS RightCare, NHS Atlas.
Available at: http://www.
rightcare.nhs.uk/index.
php/nhs-atlas/

In a 2013 article James Raftery, professor of
health technology assessment at the University
of Southampton, suggests that at least one factor
undermining the conditions for a successful
implementation of value-based pricing has been
the fact that NICE’s unfettered ability to decide
which drugs were available on the NHS has come
under regular attack for a number of years.13
He
notes that although NICE generally produces
negative guidance on less than one-third of the
drugs it evaluates, these decisions have been
“politically difficult”; the 2009 PPRS scheme
included a provision, known as the patient
access scheme (PAS), which allowed companies
to negotiate price reductions for drugs refused
by NICE. The same year NICE’s decision to reject
drugs for renal cancer led the government to
require it to apply less stringent criteria for
end-of-life drugs, leading to the reversal of
NICE’s decision on at least one of the drugs at a
cost of £549m a year.14
Meanwhile, the number
of PASs in operation has grown significantly. As
of 2015 the Department of Health had approved
48 such programmes, most of which consisted of
straightforward price discounts.15
In 2010, amid vocal media campaigns by patients
denied cutting-edge drugs, the government
established the Cancer Drugs Fund (CDF), which
was intended to run until March 2016 and fund
medicines that NICE had not yet reviewed or had
rejected regardless of price. The fund had an
initial annual budget of £200m to allow patients
access to drugs that would otherwise not have
been regularly available on the NHS. The budget
was increased to £280m in 2014-15 and £340m
in 2015-16.16
More recently, the government has
allowed NHS England to negotiate prices with
manufacturers and exclude some medicines on
cost-benefit grounds.
Yet in February 2016 members of parliament
publicly chastised NHS England and the
Department of Health for their management of
the CDF, arguing that the government still had
13
Raftery, Value based
pricing, p. 1.
14
Ibid.
15
Sackman, JE and
Kuchenreuther, MJ,
“Value-based Healthcare
in the United Kingdom,”
Pharmaceutical Technology,
Vol. 39, Issue 1, January
2nd 2015.
16
“NHS increases budget
for cancer drugs fund from
£280 million in 2014/15 to
an expected £340 million
in 2015/16”, NHS England,
January 12th 2015.
Available at: https://www.
england.nhs.uk/2015/01/
cancer-drug-budget/
17
“Government has no
idea about Cancer Drug
Fund’s Impact, MPs say,”
The Guardian, February 5th
2016. Available at: http://
www.theguardian.com/
society/2016/feb/05/
government-has-no-idea-
about-cancer-drugs-funds-
impact-mps-say
18
Raftery, Value-based
pricing, p. 2.
19
Claxton, K, Sculpher, M
et al, “Causes for Concern:
Is NICE Failing to Uphold
its Responsibilities to all
NHS Patients?”, Health
Economics, 2015, Vol. 24,
Issue 1, pp. 1-7.
20
Association of the British
Pharmaceutical Industry,
Understanding the 2014
Pharmaceutical Price
Regulation Scheme, p. 6.
21
Ibid., p. 2.
22
Ibid., p. 4.
little idea what, if any, benefit patients were
getting from the medicines the Fund pays for.17
Some analysts note that the CDF and other
initiatives only served to further cloud the way in
which NICE, and by extension the health system,
was measuring value, and that they exacerbated
the tensions over who defines it. “There needs to
be flexibility, but it needs to be made explicit,”
says Professor Chalkidou of NICE International.
“Why is a cancer patient with advanced disease
valued more highly than a 55-year-old who
needs a hip replacement to go about their daily
activities?”
In his 2013 article Professor Raftery notes that
the cost to the NHS of the patient access, end-of
life and CDF schemes has been just under £1bn,
amounting to around 1% of NHS total spend
and around 10% of its drug spend at the time.
Industry, he argues, saw value-based pricing
as “a way of avoiding NICE refusals.”18
The
government, however, continued to struggle to
define how value-based pricing would work.
In particular, according to a 2015 article in
Health Economics, a critical aspect that needs
to underpin any cost-effectiveness assessment
is not only what additional costs and benefits
a new drug might offer, but how much health
is expected to be “displaced” or lost elsewhere
given limited resources in the health system.19
Ultimately, the Department of Health shelved
plans to introduce value-based pricing, instead
negotiating the current PPRS scheme, which
held NHS spending on branded drugs unchanged
during 2013-15 and capped the growth of
expenditure at less than 2% for the next three
years.20
The aim is to provide a balance between
patient access to medicines and the need for
keeping government spending under control.21
The 2014 PPRS scheme also outlined a UK-wide
scheme for tendering and procurement of
branded, licensed NHS medicines in primary care
across the four health departments of the UK.22

“My view is that the reason this happened was
that there didn’t appear to be any discussion of
an effective price-negotiation mechanism,” says
Professor Karl Claxton, a senior research fellow at
the Centre for Health Economics at the University
of York. “The second thing was that the whole
debate focused instead on a discussion of what
the other aspects of value are.” In particular,
he adds, the realisation by industry and other
stakeholders that the discussion would need to
encompass not only the added benefit but also
the opportunity costs of new treatment caused
support to evaporate.

Policymakers have had some success in
introducing pay-for-performance incentives,
such as Quality and Outcomes Frameworks
in primary care and Best Practice Tariffs in
secondary care, according to provisional studies.
In the case of innovative treatments, a key focus
of high expenditure, however, it is not clear that
the system is any closer to a threshold that will
both achieve general acceptance and make it
clear where opportunity cost lies.
Healthcare reformers in the UK have also sought
to address sharp variations in healthcare
outcomes across the country. Innovative ideas in
this area include the triple-value framework and
the NHS RightCare programme.
Given that many of the changes to the UK system
are relatively new, a continued period of trial and
error is likely to be necessary to collect sufficient
data to draw firmer conclusions about how to
improve health outcomes and reduce health
inequalities in the country.
The UK healthcare system, and NHS England in
particular, has experimented with value measures
in health technology assessment for more than
a decade. Yet it remains uncertain whether this
process has left it in a better position than other
European countries in which notions of value are
even less developed.
Take clinical commissioning groups, for
example. They are meant to increase the power
of clinicians. However, they do not yet have a
strategic role that could help them to define
outcomes.
Meanwhile, although health technology
assessment is advanced in the UK, deficiencies
remain. NICE uses quality-adjusted life years to
measure health benefit in its cost-effectiveness
analyses, while prices of branded prescription
medicines are set by a voluntary scheme, the
Pharmaceutical Price Regulation Scheme.
However, questions remain about whether these
approaches provide the right balance between
controlling healthcare costs and boosting patient
access to innovative treatments.
Conclusion

While every effort has been taken to verify the
accuracy of this information, The Economist
Intelligence Unit Ltd. cannot accept any
responsibility or liability for reliance by any person
on this report or any of the information, opinions
or conclusions set out in this report.

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Value-based healthcare in the UK: A system of trial and error

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Value-based healthcare in the UK: A system of trial and error