ObjectiveExplore the cost-effectiveness of lifestyle interventions and metformin in reducing subsequent incidence of type 2 diabetes, both alone and in combination with a screening programme to identify high-risk individuals.DesignSystematic review of economic evaluations.Data sources and eligibility criteriaDatabase searches (Embase, Medline, PreMedline, NHS EED) and citation tracking identified economic evaluations of lifestyle interventions or metformin alone or in combination with screening programmes in people at high risk of developing diabetes. The International Society for Pharmaco-economics and Outcomes Research’s Questionnaire to Assess Relevance and Credibility of Modelling Studies for Informing Healthcare Decision Making was used to assess study quality.Results27 studies were included; all had evaluated lifestyle interventions and 12 also evaluated metformin. Primary studies exhibited considerable heterogeneity in definitions of pre-diabetes and intensity and duration of lifestyle programmes. Lifestyle programmes and metformin appeared to be cost effective in preventing diabetes in high-risk individuals (median incremental cost-effectiveness ratios of £7490/quality-adjusted life-year (QALY) and £8428/QALY, respectively) but economic estimates varied widely between studies. Intervention-only programmes were in general more cost effective than programmes that also included a screening component. The longer the period evaluated, the more cost-effective interventions appeared. In the few studies that evaluated other economic considerations, budget impact of prevention programmes was moderate (0.13%–0.2% of total healthcare budget), financial payoffs were delayed (by 9–14 years) and impact on incident cases of diabetes was limited (0.1%–1.6% reduction). There was insufficient evidence to answer the question of (1) whether lifestyle programmes are more cost effective than metformin or (2) whether low-intensity lifestyle interventions are more cost effective than the more intensive lifestyle programmes that were tested in trials.ConclusionsThe economics of preventing diabetes are complex. There is some evidence that diabetes prevention programmes are cost effective, but the evidence base to date provides few clear answers regarding design of prevention programmes because of differences in denominator populations, definitions, interventions and modelling assumptions.

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In 2003, the UK government set up a broad-based Committee on radioactive waste management (CoRWM) to look at the UK's policy on radioactive waste management with a view to jumpstarting a stalled policy process. The committee's brief was to come up with a set of recommendations that would protect the public and the environment, and be capable of inspiring public confidence. After consulting widely with the public and stakeholders, and drawing on advice from scientists and other experts, CoRWM arrived at a remarkably well-received set of recommendations. On the basis of our experiences of working on CoRWM's multi-criteria decision analysis of different management options, study of CoRWM documentation, and interviews with committee members, we describe the explicit and implicit principles that guided CoRWM. We also give an account of the process by which CoRWM arrived at its conclusions, covering four phases: framing, shortlisting, option assessment, and integration; and four cross-cutting activities: public and stakeholder engagement (PSE), science and engineering input, ethics and social science input, and learning from overseas practice. We finish by outlining some of the key developments in the UK's radioactive waste management process, which followed on from the publication of CoRWM's report, and present our reflections for the benefit of the risk and decision analysts of future committees that, like CoRWM, are charged with recommending to government on the management of technically complex and risky technologies, drawing on extensive public and stakeholder consultation.

This paper focuses on the contrast between describing the benefit of a healthcare intervention as gain in health (QALY-type ideas) or a disability reduction (DALY-type ideas). The background is an apparent convergence in practice of the work conducted under both traditions. In the light of these methodological developments, we contrast a health planner who wants to maximise health and one who wants to minimise disability. To isolate the effect of framing the problem from a health or a disability perspective, we do not use age-weighting in calculating DALY and employ a common discounting methodology and the same set of quality of life weights. We find that interventions will be ranked in a systematically different way. The difference, however, is not determined by the use of a health or a disability perspective but by the use of life expectancy tables to determine the years of life lost. We show that this feature of the DALY method is problematic and we suggest its dismissal in favour of a fixed reference age rendering the use of a health or a disability perspective merely stylistic.

We apply Transaction Cost Economics to social impact bonds to explore how public service commissioners might improve outcomes-based contracts. We supply a framework for assessing the quality of outcomes specifications and clarify the trade-off between a robust value case for government and the transaction costs associated with specifying such a deal. Illustrated by two examples, we suggest commissioners aim for a 'requisite' contract: one that minimises opportunism whilst balancing the costs of developing a more robust outcomes specification.