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This brief commentary seeks to develop the analysis of Daniels, Porteny and Urrutia of the implications of expansion of the scope of health technology assessment (HTA) beyond issues of safety, efficacy, and cost-effectiveness. Drawing in particular on experience in the United Kingdom, it suggests that such expansion can be understood not only as a response to the problem of insufficiency of evidence, but also to that of legitimacy. However, as expansion of HTA also renders it more visibly political in character, it is plausible that its legitimacy may be undermined, rather than enhanced by, independence from the policy process.

Dr Keith Syrett argues for a reappraisal of the role of public law adjudication in questions of healthcare rationing. As governments worldwide turn to explicit rationing strategies to manage the mismatch between demand for and supply of health services and treatments, disappointed patients and the public have sought to contest the moral authority of bodies making rationing decisions. This has led to the growing involvement of law in this field of public policy. The author argues that, rather than bemoaning this development, those working within the health policy community should recognise the points of confluence between the principles and purposes of public law and the proposals which have been made to address rationing's 'legitimacy problem'. Drawing upon jurisprudence from England, Canada and South Africa, the book evaluates the capacity of courts to establish the conditions for a process of public deliberation from which legitimacy for healthcare rationing may be derived.

Background There is an international move towards greater integration of health and social care to cope with the increasing demand on services.. In Scotland, legislation was passed in 2014 to integrate adult health and social care services resulting in the formation of 31 Health and Social Care Partnerships (HSCPs). Greater integration does not eliminate resource scarcity and the requirement to make (resource) allocation decisions to meet the needs of local populations. There are different perspectives on how to facilitate and improve priority setting in health and social care organisations with limited resources, but structured processes at the local level are still not widely implemented. This paper reports on work with new HSCPs in Scotland to develop a combined multi-disciplinary priority setting and resource allocation framework. Methods To develop the combined framework, a scoping review of the literature was conducted to determine the key principles and approaches to priority setting from economics, decision-analysis, ethics and law, and attempts to combine such approaches. Co-production of the combined framework involved a multi-disciplinary workshop including local, and national-level stakeholders and academics to discuss and gather their views. Results The key findings from the literature review and the stakeholder workshop were taken to produce a final combined framework for priority setting and resource allocation. This is underpinned by principles from economics (opportunity cost), decision science (good decisions), ethics (justice) and law (fair procedures). It outlines key stages in the priority setting process, including: framing the question, looking at current use of resources, defining options and criteria, evaluating options and criteria, and reviewing each stage. Each of these has further sub-stages and includes a focus on how the combined framework interacts with the consultation and involvement of patients, public and the wider staff. Conclusions The integration agenda for health and social care is an opportunity to develop and implement a combined framework for setting priorities and allocating resources fairly to meet the needs of the population. A key aim of both integration and the combined framework is to facilitate the shifting of resources from acute services to the community.

Background Regulatory actions are increasingly used to tackle issues such as excessive alcohol or sugar intake, but such actions to reduce sedentary behaviour remain scarce. World Health Organization (WHO) guidelines on sedentary behaviour call for system-wide policies. The Chinese government introduced the world’s first nation-wide multi-setting regulation on multiple types of sedentary behaviour in children and adolescents in July 2021. This regulation restricts when (and for how long) online gaming businesses can provide access to pupils; the amount of homework teachers can assign to pupils according to their year groups; and when tutoring businesses can provide lessons to pupils. We evaluated the effect of this regulation on sedentary behaviour safeguarding pupils. Methods With a natural experiment evaluation design, we used representative surveillance data from 9- to 18-year-old pupils before and after the introduction of the regulation, for longitudinal ( n  = 7,054, matched individuals, primary analysis) and repeated cross-sectional ( n  = 99,947, exploratory analysis) analyses. We analysed pre-post differences for self-reported sedentary behaviour outcomes (total sedentary behaviour time, screen viewing time, electronic device use time, homework time, and out-of-campus learning time) using multilevel models, and explored differences by sex, education stage, residency, and baseline weight status. Results Longitudinal analyses indicated that pupils had reduced their mean total daily sedentary behaviour time by 13.8% (95% confidence interval [CI]: -15.9 to -11.7%, approximately 46 min) and were 1.20 times as likely to meet international daily screen time recommendations (95% CI: 1.01 to 1.32) one month after the introduction of the regulation compared to the reference group (before its introduction). They were on average 2.79 times as likely to meet the regulatory requirement on homework time (95% CI: 2.47 to 3.14) than the reference group and reduced their daily total screen-viewing time by 6.4% (95% CI: -9.6 to -3.3%, approximately 10 min). The positive effects were more pronounced among high-risk groups (secondary school and urban pupils who generally spend more time in sedentary behaviour) than in low-risk groups (primary school and rural pupils who generally spend less time in sedentary behaviour). The exploratory analyses showed comparable findings. Conclusions This regulatory intervention has been effective in reducing total and specific types of sedentary behaviour among Chinese children and adolescents, with the potential to reduce health inequalities. International researchers and policy makers may explore the feasibility and acceptability of implementing regulatory interventions on sedentary behaviour elsewhere.

There is a move, internationally, towards greater integration of health and social care. In principle, integration reduces budgetary boundaries which can facilitate sharing of resources across health and social care. Part of the agenda is for local delivery organisations to alter the balance of care from acute to community environments. To facilitate this shift, against a background of increasing austerity, there is a need for robust processes for making difficult resource allocation decisions which meet the standards of disciplines such as economics, ethics, law and decision science. In 2014, the Scottish Government established 31 Health and Social Care Partnerships (HSCPs) acting as single commissioners to deliver this agenda.The aim was to develop and implement an enhanced, multi-disciplinary framework for priority setting, for use by four HSCPs, and assess its impact on processes, decision-making and resource allocation.MethodsTo develop the framework, a literature review was conducted. The findings form the review were combined with input from key stakeholders including, academics, local and national-level stakeholders. During implementation of the framework, Participatory Action Research was undertaken to explore how the framework functioned within HSCPs, to document how participants engaged with the framework and to consider how the framework could be adapted to an integrated institutional setting. Interviews were conducted before and after working with the framework.ResultsThe framework is underpinned by principles from economics (opportunity cost), decision-analysis (good decisions), ethics (justice) and law (fair procedures). Three sites worked through the process and made recommendations. Proposed recommendations include disinvestment and reallocations within budget areas. Despite challenges, stakeholders’ views were that such a framework is required to move from resource allocations being based on historical budgets and service provision and encourages transparent decision making involving wider stakeholders. Increased pressure on resources has made such frameworks even more critical for decision making.

Judicial readings of the right to health—and related rights—frequently possess something of an “all or nothing” quality, exhibiting either straightforward deference to allocative choices or conceptualizing the right as absolute, with consequent disruption to health systems, as witnessed in Latin America. This article seeks to identify pathways through which a normatively intermediate approach might be developed that would accord weight to rights claims without overlooking the scarcity of health resources. It is argued that such development is most likely both to accompany and support a role for courts as institutions functioning within a society that is characterized by a deliberative conception of democracy.

The vision of global health with justice which Larry Gostin articulates in his book Global Health Law envisages a switch to ‘upstream’ priority-setting for expenditure on health, with a focus upon social determinants and a goal of redressing health inequalities. This article explores what is meant by this proposal and offers a critical evaluation of it. It is argued that difficulties arise in respect of the ethical and evidential bases for such an approach to the setting of priorities, while significant challenges may also arise in the necessary modification of structures of governance.

Recommendations issued by agencies undertaking appraisals of health technologies at the national level may impact upon the availability of certain treatments and services in some publicly funded health systems, and, as such, have regularly been subject to challenge, including by way of litigation. In addition to expertise in the evaluation of evidence, fairness of procedures has been identified as a necessary component of a claim to legitimacy in such circumstances. This article analyses the assessment of courts in three jurisdictions of the fairness of decision-making by such agencies and evaluates the judicial reading of procedural justice developed in this particular context against the conditions of ‘accountability for reasonableness’.

This paper offers a brief comment on Jennings' preceding paper, focusing on the capacity of a republican approach to public health ethics to facilitate reconceptualization of the right to health in situations of limited resources through a relational reading.