Should we make the priority setting process more explicit to the public? Dr Benedict Rumbold

1. Should we make the priority setting process more explicit to the public? Dr Benedict Rumbold

2. ‘Pay no attention to the man behind the curtain!’ • At present, priority setting process is semi-public; the curtain has been drawn back, but not completely. • The public are aware that priority setting takes place but not: • Who is responsible for decision making • What basis decisions are made on • We need to decide whether to either: • Make the process more transparent • Publicly endorse an obscurity – be ‘explicitly implicit’ (Chinitz, 1998) Toto reveals the Wizard - The Wizard of Oz (1939)

3. Current practice in theEnglish National Health Service • Questionnaires sent out to all 152 Primary Care Trusts in England. • 115 responses from 74 out of 152 PCTs (49%). • Survey results suggest that 70% of PCTs have a formal priority setting boards. • Respondents asked to highlight which aspects of the priority setting process PCTs make available to the public.

4. Question: Which of the following aspects of the priority setting process does your PCT make explicit to the public?

5. The case for publicity • Argument from rights - Public has a ‘right to know’. • Argument from democracy and fairness – Publicity is necessary for informed consent and fair dealings. • Argument from pragmatism - Publicity guards against inconsistency, unjust preferences and groundless exceptions. © Getty Images

6. Why do priority-setters make the process so unclear? • Interviews yet to take place – but working hypothesis is they want to avoid blame. • But what is blame and why are priority-setters so concerned about it? • Blame: • Perception of harm • Perception of responsibility • Worry of priority-setters is that, by its very nature, priority-setting involves causing harm – e.g. by denying healthcare to people who would benefit from it. • So, blame is seen as inevitable, hence their interest in strategies of blame-avoidance (especially limiting perceptions of responsibility).

7. Priority-setting and vagueness • Within the priority-setting process, who makes the decisions, and the basis on which decisions are made is not always clear cut. • E.g. a decision may be the result of many actors working together and/or independently, each of whom may be relying, say, on moral intuition rather than a definitive set of principles. • However, in the public sphere, vagueness in either the decision-making process or on the part of the decision makers themselves is usually frowned upon. • As such, actors may be unwilling to take responsibility for their part in a vague system, given vagueness is accepted within the system but castigated outside it. © Getty Images

8. Persuading actors to make the priority setting process explicit • Raise the possibility of praise? Unlikely to be effective … • Typically, decision-makers are so fearful of blame they would prefer to avoid taking any responsibility even if that meant giving up possibility of praise (Weaver, 1986) • In order for priority-setters to be praised there needs to be some perception of benefit. But, as established, priority-setting always results in some kind of harm. The best a priority-setter can hope for is the public praising them for fairly distributing harms – unlikely to receive much praise for this. • Instead, priority-setters need to be persuaded either: • That allowing for the possibility of blame is a price worth paying. • Not all publicity need lead to blame. © Getty Images

9. Publicity can be good, even if it means more blame Hood suggests blame can: • Encourage decision-makers to ‘win the argument’. • Improve the delegation of responsibility within decision-making hierarchies. • Encourage decision-makers to follow set rules and processes – to ‘take care’. (Hood, 2010) National Library NZ

10. complete publicity has costs • Complete publicity can negatively effect the decision-making process: • Moving from private, particularistic reasons to truly public reasons may then often have an associated price, i.e., shifting from profound (private) reasons to shallow or manipulative (public) reasons (Chambers, 2004). • Also, complete publicity rarely allows for vagueness, and vagueness in the priority-setting process may not only be necessary but also something we want to hang on to (e.g. Mechanic, 1997). The villagers confront Frankenstein – Frankenstein (1931)

11. Rationing and reaching the point of trust • Need a level of publicity that allows for responsibility and public knowledge but which also allows for the possibility of vagueness. • One possible option is combining an explicit model with a sustained effort to increase public trust in priority-setters themselves. • Trust may give priority-setters the elbow room to be vague, and to avoid shallow or manipulative (public) reasons – i.e. to be explicitly implicit. © Getty Images

12. www.nuffieldtrust.org.uk benedict.rumbold@nuffieldtrust.org.uk

13. References • Chambers, S (2004) “Behind Closed Doors: Publicity, Secrecy, and the Quality of Deliberation”, Journal of Political Philosophy 12(3): 389-410 • Chinitz, D., Shalev, C., Galai, N. & Israeli, A. (1998) ‘Israel’s basic basket of health services: the importance of being explicitly implicit’, BMJ, 317, 1003-7 • Hood, C (2010) ‘Risk and Government: The architectonics of blame-avoidance’, Darwin College Lecture Series - February 2010 • Mechanic, D., (1997), ‘Muddling Through Elegantly: Finding the proper balance in rationing’, Health Affairs 16 (5) 83-92. • Weaver, R K (1986) ‘The Politics of Blame Avoidance’ Journal of Public Policy 6 (4): 371-98.