Priority Setting and the Public

Penelope Mullen, Peter Spurgeon

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138444287
• eBook ISBN: 9781315348568
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Practical and evidence-based, this unique book is the first comprehensive text focused on person-centered approaches to people with serious mental illness such as schizophrenia and bipolar disorder. It reflects a range of views and findings regarding assessment, treatment, rehabilitation, self-help, policy-making, education and research. It is highly recommended for all healthcare professionals, students, researchers and educators involved in general practice, psychiatry, nursing, social work, clinical psychology and therapy. Healthcare service providers, and policy makers and shapers, will find the book's wide-ranging, multi-professional approach enlightening. 'Serious Mental Illness reflects a continued distancing from the outmoded and unsubstantiated belief that people with severe mental illnesses could not recover, and that they would respond positively only to goals and treatment plans chosen, designed and implemented by providers in order to prevent their further deterioration. Anyone with an interest in the concept of person-centered approaches will discover new ideas in this book. Indeed, anyone with an interest in person-centered approaches has to read this book. Not only is it the first such book on person-centered approaches, but it will serve as the gold standard in this topic area for years to come.' William A Anthony, in the Foreword

CHAPTER ONE

The context of change in health systems

Introduction

Within the UK National Health Service (NHS) in recent years, in common with many other countries, there has been an upsurge of interest in explicit priority setting and also in the involvement of the public in decisions about healthcare provision. These two strands of thinking represent the focus of this text and will be explained in detail in subsequent chapters. However, priority setting is not merely a technical issue. It cannot be viewed in isolation from the rationing debate and priority setting within any healthcare system will be influenced, or even controlled, by the ideology of that system (Williams, 1988). Many of the forces providing an impetus to priority setting parallel the more general pressures to overall health system ‘reform’ or review. Therefore, before priority setting is examined specifically, a brief overview of the factors influencing health system ‘reform’ will be given.

The process of health system ‘reform’ is virtually universal in developed, and increasingly in developing, societies and by and large the forces advanced as promoting the ‘reform’ process are described in similar terms. They may be summarised as:

• a perceived need for governments to constrain the increasing costs of healthcare systems against a background of apparently ever-increasing demand
• rapid advances in medical technology and drugs which at once may increase short-term costs and radically change the way in which services are provided
• an increasing elderly population presenting complex multiple pathologies and requiring extended long-term care (Spurgeon, 1993).

In the UK, the previous Conservative government (through the 1980s and much of the 1990s) was driven in its attitude to public services by three fundamental and pervasive values or principles, which have particular importance for the subsequent interest in priority setting.

The first of these was a strong desire to move as much public sector provision as possible into the private sector, which was perceived by the government to be both more efficient and more responsive (Pollitt, 1986). Where that was not possible, there were attempts to introduce the ‘disciplines’ of the private sector and the market to the public sector.

This leads to the second principle, which was a strongly voiced concern for increased accountability at both institutional and personal levels, whereby public organisations were to be made more directly accountable for how public money was used. Clearly such financial scrutiny readily translates into questions of which health services should be purchased, whether this represents the best use of public money or whether alternative choices might have been made.

The third principle was the government’s expressed desire to increase consumer choice, whether directly in respect of services received or by agents on behalf of the consumer. Once again, this desire has been translated into advocating an enhanced role for consumers (the public) in determining the nature of health services to be made available.

Such values were expressed through the creation of the Internal market’ in healthcare and were operationalised as:

• the separation of purchaser and provider roles with contracts or service agreements as the basis of the purchaser-provider relationship
• the establishment of NHS trusts as quasiautonomous organisations responsible for the provision of healthcare
• the creation of GP fundholding (GPFH), enabling some GPs to purchase a range of services on behalf of their registered patients.

It was hardly surprising that the ‘reform’ process contained inherent tension and conflict since the pre-1991 NHS had generally provided a comprehensive service with reasonable equity of access, with health outcomes comparable to other health systems, and at a total cost in 1990 of 6% of Total Domestic Expenditure (TDE) in the UK as compared to a European average of 7.5% of TDE (OECD, 1993). The ‘reform’ process should perhaps have been more appropriately targeted at those aspects of the NHS which might be described as rigid and unresponsive to pressures for change and lacking incentives for improvement in efficiency. A rather more extreme strategy to introduce a substantial element of private funding to supplement public expenditure (Letwin and Redwood, 1988) was rejected. Thus, in essence, the changes to the NHS were designed to change the delivery system to encourage greater efficiency, whilst preserving the basic method of financing the service and operating within the same broad financial parameters.

A very strong directional force to the subsequent priority-setting debate can be detected here with the explicit goal of obtaining greater value from a constrained budget. The expression of this choice mechanism through contracts set between purchasers and providers was in effect an attempt to obtain greater allocative efficiency (Posnett, 1993). Within the new NHS structure, both health authorities (HAs) and GP fundholders performed the purchasing function. The common feature of assessing the needs of their (resident or registered) population and then purchasing to meet those needs is the critical component relevant to priority setting. Both HAs and fundholders were charged with obtaining value for money and hence making choices between different types of healthcare provision. In a parallel process, providers were to organise themselves to respond to purchaser requirements and to compete against one another to secure contracts by providing services in the most efficient and cost-effective manner.

The expressed intention of the separation of the purchasing function from the provision of healthcare was to provide greater freedom and independence for the purchaser in planning contracts in the best interests of the population rather than the vested interests of the provider organisation. The fact that this did not really happen other than at the periphery was largely due to the immaturity of purchasing as a function within the NHS and also to the major imperfections of healthcare as a market environment (Spurgeon, 1997).

Nonetheless, it is fair to say that within an overall budget framework, purchasers began to set priorities for treatment, to evaluate the cost-effectiveness of alternative procedures and to develop measures of healthcare outcomes as part of the process of monitoring and evaluating the performance of suppliers. The documentation of contracts was increasingly making priority setting more transparent and open to public scrutiny – and concern (Moore, 1996). Recent high-profile cases relating to the cost of new drugs such as interferon-(3 for multiple sclerosis sufferers (Zimmern, 1995) and the denial of treatment to Child B by her health authority (New and Le Grand, 1996) are examples of both the process of priority setting at work and the potential volatility of public reaction once such decisions become explicit.

Continuing processes of ‘reform’ and factors increasing the interest in priority setting

Ever since the inception of the NHS, access to healthcare has been restricted in one form or another. These restrictions, which are now frequently termed Implicit rationing’, have taken a variety of forms including waiting and raising the threshold for treatment. However, the inception of the Internal market’ was accompanied by an increasing interest in ‘explicit rationing’, which is usually understood to mean deciding explicitly which services or treatments will be provided by the NHS and which will not (for examples, see Brindle, 1995a, c; RCP, 1995). Whilst this had always been done to some extent at the national level, by declaring that certain forms of treatment or drugs were not available on the NHS, the new focus on rationing was found at the level of the purchaser (HA or GP fundholder).

The major reason for this change in decision-making focus lay in alterations to the way hospitals and other healthcare providers were funded. Under the old pre-1991 NHS, hospitals were directly funded and managed by their HAs. Planners and politicians could influence priorities by determining which facilities/services to provide and their location, thus restricting access both by capacity and by distance. But within the overall resource allocation, most ‘rationing’ was controlled by clinicians, via waiting and thresholds. Under the post-1991 contract-based system, with the purchaser-provider split described above, purchasers were able to determine explicitly, and in some detail, what services/treatments they would and would not purchase for their resident or registered populations. This opened up the possibility of explicit rationing which some, for instance Ham (1998), argue is a better system than the implicit rationing of the past.

However, it must also be acknowledged that such an approach may also act as a shield to politicians unwilling to be seen to restrict services themselves and preferring to place other organisations in the battleground of withdrawal of health provision. Moreover, with greater explicitness, a rigidity in decision making is introduced, necessitating guidelines, protocols, criteria, etc., unlike previous approaches which, although somewhat fuzzy, may have had greater scope to absorb difficult decisions. This is an issue we will return to in later chapters.

The problems and opportunities afforded by the purchaser-provider split are likely to continue. The Labour government, which was elected in May 1997, stated in the White Paper The New NHS (DoH, 1997) its intention to abolish the internal market introduced by the previous government. However, decisions on which services to ‘purchase’ or ‘commission’ will remain at local level, mainly in the hands of primary care groups (PCGs), led by general practitioners and responsible for populations of around 100 000, with HAs performing a co-ordinating and strategic planning function.

Certainly, the move from ‘implicit’ to ‘explicit’ rationing has created a vast range of debates and controversy. The separation of purchaser from provider, although a major contributor in the factors leading to increased interest in priority setting, is not the sole impetus. A number of other developments in healthcare systems have served to reinforce this process.

National priorities and planning guidelines

The Priorities and Planning Guidance 1997–98 issued to the service by the NHS Executive in 1996 (NHSE, 1996a) attempted to provide an overall context for the planning and delivery of health services and to focus local decision makers on the most important national priorities. The content of the guidelines is not really the point and, indeed, they have been changed by the incoming Labour administration. Their importance is to be seen in the relationship between national government and the local allocators of resources. The latter, HAs and purchasing GPs, are aware that they will be monitored in terms of their performance against national priorities. Thus, where such priorities require additional resources in order to be achieved, it is immediately possible that decisions may be needed to redirect resources to these target areas, i.e. priorities will have to be set.

In addition, nationally determined Patient’s Charter standards, such as waiting-time targets, can create prioritisation decisions – or distortions, as some would argue. Finally, national guidelines are frequently supplemented by within-year imperatives, so clearly purchasing strategies must operationalise some form of priority setting in order to balance delivery against these (often competing) goals.

Healthcare needs assessment

Purchasers have a responsibility to meet the needs of their population, whether resident or registered, but the concept of need is subjective, dynamic and multidimensional. There is a major area of debate and discussion surrounding the concept of need and it cannot be covered in depth here. However, the debate around needs assessment neatly exemplifies some of the competing perspectives which must be reconciled if an acceptable priority-setting process is to emerge.

Possibly the dominant perspective is that based on the epidemiological/medical approach, which equates health need with the presence of disease in a population (Foreman, 1996). Thus the extent of illness is used as a basis to assess both need for health and need for healthcare. However, Culyer and Wagstaff (1993, p.434), who examine a number of definitions of need, are especially critical of the argument that ‘persons who are more ill than others have a greater need’, a notion that underlies many of the empirical studies. They suggest that ‘it is hard to see why someone who is sick can sensibly be said to need health care, irrespective of the latter’s ability to improve the person’s health’.

The notion of ‘capacity to benefit’ leads to the second perspective, widely advocated by health economists, which places much greater emphasis upon the cost-effectiveness of treatments. This leads to the argument that resources should be allocated and priorities set in order to maximise the total benefit obtained from those resources; resources should be allocated to those treatments and services which achieve the most quality-adjusted life years (OALYs) per pound.

The rather technical aspect of that approach is in contrast to the third perspective (the social approach) which is more holistic and seeks to incorporate aspects of an individual’s social, economic and environmental situation. This perspective is associated with definitions of health which go beyond the ‘absence of disease’, as exemplified by the World Health Organisation definition: ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Daniels (1985, p.32) suggests that ‘Health care needs will be those things we need in order to maintain, restore, or provide functional equivalents (where possible) to normal species functioning’, impairments to which, he argues (p.27), ‘reduce the range of opportunity open to the individual’. This range – the normal opportunity range – ‘for a given society is the array of life plans reasonable persons in it are likely to construct for them selves’ (p. 33) and is thus dependent on key features of that society including historical and technological development, material wealth and culture.

Foreman (1996, p.69) argues that ‘While the epidemiological and social models would attempt to meet all the needs that fall within their respective definitions, the economic model effectively replaces needs with the more restricted concept of priorities’. The latter model has gained some ascendancy in recent years. In many senses, the arguments surrounding the health-maximising approach capture the essence of the priority-setting tension: how far should healthcare systems seek to meet needs as defined by the social and/or medical approaches as opposed to focusing on the most cost-effective interventions?

Primary care-led services

Along with many countries, the UK has seen a proliferation of initiatives designed to shift the focus from secondary to primary care. Despite assumptions by some proponents of a primary care-led NHS that healthcare provision by generalists rather than specialists and an enhanced gatekeeper role for prima...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• About the authors
• Chapter 1 The context of change in health systems
• Chapter 2 Setting priorities and healthcare rationing
• Chapter 3 Consumer involvement in healthcare
• Chapter 4 Priority setting, rationing and the consumer role
• Chapter 5 Engaging the public
• Chapter 6 Eliciting values for priority setting
• Chapter 7 Priority-setting approaches in practice
• Chapter 8 Key concepts – the continuing debate
• Appendix Overview of techniques for eliciting values
• References
• Index