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The UK Employment Tribunal System (ETS) is broken and in need of reform according to the British Chamber of Commerce (BCC) (2011) and the Confederation of British Industry (CBI) (2011). Both organisations, that represent and lobby in the interests of employers, have carried out research which purports to show tribunals are too alacritous in accepting spurious claims and that the cost to defend a claim is higher than settling. In contrast the Trades Union Congress (TUC) (2011) and ETS commentators have consistently argued that the tribunal system favours employers through its judgments and ability to compensate, and needs to be reformed to address this lack of fairness, specifically the remedies awarded to claimants can be minimal in terms of potential career earnings, and the psychological impact of the tribunal process can be very damaging. Focusing on three areas of social justice identified by Rawls (2005) and Cropanzano, Stein and Nadisic (2011) this study argues that although the ETS is an important mechanism for adjudicating workplace disputes, there are major concerns regarding the inclination to defend cases and the willingness to follow a claim to a full tribunal hearing. Implications are drawn from these superficially similar viewpoints as to how the government can continually monitor, evaluate and reform the tribunal system. The study considers the proposition that tribunals should favour employees, as they have more to lose from the process, and it implies that if justice is both carried out and also perceived to be administered, the ETS has to be continually modernised to meet the expectations of those involved with the process. The law is stated as at October 2013.

Background: Transferring cost-effectiveness information between geographic domains offers the potential for more efficient use of analytical resources. However, it is difficult for decision-makers to know when they can rely on costeffectiveness evidence produced for another context. Objectives: This thesis explores the transferability of economic evaluation results produced for one geographic area to another location of interest, and develops an approach to identify factors to predict when this is appropriate. Methods: Multilevel statistical models were developed for the integration of published international costeffectiveness data to assess the impact of contextual effects on country-level; whilst controlling for baseline characteristics within, and across, a set of economic evaluation studies. Explanatory variables were derived from a list of factors suggested in the literature as possible constraints on the transferability of costeffectiveness evidence. The approach was illustrated using published estimates of the cost-effectiveness of statins for the primary and secondary prevention of cardiovascular disease from 67 studies and related to 23 geographic domains, together with covariates on data, study and country-level. Results: The proportion of variation at the country-level observed depends on the appropriate multilevel model structure and never exceeds 15% for incremental effects and 21% for incremental cost. Key sources of variability are patient and disease characteristics, intervention cost and a number of methodological characteristics defined on the data-level. There were fewer significant covariates on the study and country-levels. Conclusions: Analysis suggests that variability in cost-effectiveness data is primarily due to differences between studies, not countries. Further, comparing different models suggests that data from multinational studies severely underestimates country-level variability. Additional research is needed to test the robustness of these conclusions on other sets of cost-effectiveness data, to further explore the appropriate set of covariates, and to foster the development of multilevel statistical modelling for economic evaluation data in health.

There is a growing recognition that we cannot afford the provision of all new health care technologies, even those that are proven to be beneficial. This is increasingly true in the US, where health care spending is on an unsustainable upward trajectory. US health care spending is greatly in excess of that of other countries; however, with respect to key health metrics, the US health care system performs relatively poorly. Despite this, unlike many other developed countries economic evaluation, and more specifically cost effectiveness evidence, is used sparingly in the US health care system. Notably, the Centers for Medicare and Medicaid Services (CMS), administrators of the Medicare programme, state that cost-effectiveness evidence is not relevant to coverage decisions for medical technology and interventions evaluated as part of National Coverage Determinations (NCDs). The empirical aspect of this thesis evaluates the current use and potential value of using cost-effectiveness evidence in CMS NCDs. A database was built using data obtained from NCD decision memoranda, the medical literature, a Medicare claims database, and Medicare reimbursement information. The findings of the empirical work show that, CMS’s stated position notwithstanding, cost-effectiveness evidence has been cited or discussed in a number of coverage decisions, and there is a statistically significant difference between positive and non-coverage decisions with respect to cost effectiveness. When controlling for factors likely to have an effect on coverage decisions, the availability of cost-effectiveness evidence is a statistically significant predictor of coverage. In addition, the quality of the supporting clinical evidence, the availability of alternative interventions, and the recency of the decision are statistically significant variables. Further, when hypothetically reallocating resources in accordance with cost-effectiveness substantial gains in aggregate health are estimated. It is shown that using cost-effectiveness to guide resource allocation has an effect on resource allocation across patient populations and types of technology.