Priority setting in difficult times: the English experience

1. Health Services Management Centre Priority setting in difficult times: the English experience Suzanne Robinson, Iestyn Williams, Helen Dickinson and Tim Freeman

2. Setting priorities in health care • Resource allocation – how we spend our limited resources • Policy response • development of HTA agencies • Devolution of resource allocation function to regional or local levels • NICE: provide policy directives that local payers are required to implement • PCT : responsible for allocation of approximately 85% of the total health budget

3. English Policy context: Purchaser provider split • PCT : responsible for allocation of approximately 85% of the total health budget • World Class Commissioning Agenda- PCTs required to ‘deliver better health and well being for all, better care for all and better value for all - adding life to years and years to life’ • NICE: provide policy directives that local payers are required to implement – but only partial resolution of demand and supply imbalance • PCTs are required to devise supplementary strategies for setting priorities- • range of tools and approaches to aid the priority-setting process at local levels have been developed.

4. Health care policy: the World Class Commissioning (WCC) agenda • Increased competition, accountability and transparency • Implied rationality and EBA to decision making- RCTs, CEA and Programme Budgeting Analysis (PBMA), national guidance (NICE) • Disinvestment as well as investment to be considered • Focus on local- enables local service design, innovation and development • Engage with all stakeholders – including patients and the public • Planned approach to financial management sustainable future focused -monitor performance and withdraw if not meet

5. The research focus • Research -tended to focus on how different forms of economic evidence has been used to inform and shape priority setting processes • Our work is interested in the enactment of priority setting in the local setting • Focusing on how decision makers are actualising processes through their management practices

6. The local reaction: the case study site • The PCT executive and commissioning team identified that • commissioning was driven by historical trends and arrangements • General perceptions that old system was inconsistent, lacked transparency • Involved only a small number of individuals in actual decision making • No systematic feedback mechanism • No appeals procedure • Central gov’t policy accelerated policy change

7. The new priority setting process • Follows the Accountability for Reasonableness framework (AFR) Daniels and Sabin, 1998- requirement to include deliberation and debate- • Two stage process- • Development and submission of proposals (bids) to PCT • Panel session (4) to discuss bids and make recommendations to executive team about which bids should be funded • Modified scoring tool developed to aid the decision making process focus on: CEA; number of patients who would benefit; risks associated with non-funding and demonstration of clinical engagement

8. Methods of data collection • Observations of panel sessions • Evaluation of documentary evidence • Interviews with a range of stakeholders

9. Methods of data analysis: Interpretive approach • This approach allows us to incorporate human meaning and meaning making which is comprised of beliefs, but also values and feelings/sentiments, all very much part of policy problematics. • How differences may be creating a dissonance between the intent of the process (rational planning) and its ability to deliver in practice • Meanings are communicated through metaphors • Communities of meaning – share a common understanding of a problem-

10. Descriptive Results • 91 bids were scored across 4 panel sessions • 68 were actually scored • Top 22 bids funded • Number of members ranged from 11 (panel 4)- 16 (panel 3) • Breath of experience and skills was seen as a strength of panel • Deliberative element was not codified

11. Two - Communities of Meaning (CM) • CM 1- antagonistic view towards policy protect the ‘old way of doing things’ • CM2 – very much in favour of policy ‘Time for a change’

12. CM 1: Dragon's Den • Lots of emotional responses – attached to Metaphor- discomfort with level of questions asked of bid authors, could demoralise staff “Bidding was like being “thrown to the lions” or being “lined up in front of the firing squad”           • “The process left me feeling battered”

13. CM 2: Dragon's Den • Positive – symbolised fairness, transparency, encourages innovation and entrepreneurship • Detailed questioning and probing were seen as crucial elements of the process • “Questioning was fair, but a lot intimidated (referring to bid authors) but we are dishing out public money so needs to be challenging”

14. Response to the rational process • Both communities demonstrated dissonance with the rational process of Priority setting tended to relate to lack of evidence • CM1-process flawed – not fit for purpose tended to go with ‘gut instinct’- own knowledge and expertise “tool not fit for purpose complex criteria that is not transferable to this setting…I just went with my ‘gut instinct’ used by own experience

15. Response to rational process • CM2- shift towards rational model welcomed change better – overcome lack of information by being consistent in approach to scoring “I think by being consistent you are being fair to all bids and it all gets sorted in ‘the wash’ that way…”

16. CM1: Tool and process • CM1 suggested that the tool got in the way of the process and the same outcome could be achieved without it “The process was costly and no better than a back of the envelope calculation which probably would come up with the same answer”

17. CM2: Tool and process • The tool helped to structure the process makes the process more defensible. “…it aids the process, helps to structure it and we are all singing from the same hymn sheet if you get my meaning…helps when we are questioned about our decision, last year we could not say why things got funded and others didn’t this year we can…

18. What does this tell us? • Tensions between rational approach to decision making and the performance of decision making • Attempt to import approaches provokes dissonance between stated intent and ability to deliver in practice • Different communities arise that have different responses to the policy change- some explicit others less so

19. Any questions/ observations?