Priority setting in practice; procedures, results, and participants’ opinions

1. Priority setting in practice; procedures, results, and participants’ opinions Susanne Waldau PhD candidate Umeå University; Strategic prioritisation advisor, VCC

2. Västerbotten County Council, Sweden A politically managed, regional health care organisation Taxing & financing of health care 250 000 inhabitants 10 000 employees 1 university hospital + 2 district hospitals ~ 30 primary care units Regional culture & development

3. Background • Clearly exposed demands for funding of new technologies (~ 1,5% / year) • Expected economic strain • Identified need for a change of organisational behaviour (ie, ”Start respecting budget limits!”) • Long-term political interest in priority setting

4. Political instructions ”Create a process for priority setting” Desired features: • Secure openness in decisions & reasoning • Include the entire organisation • Create a forum for sharing of knowledge between politics, management and health care • Make use of the medical professions’ expertise • Political leadership takes on responsibility for reallocation decisions

5. Aim of the process To fund new medical technologies by disinvesting in low priority services; ie, Reallocation of given resources to improve cost effectiveness

6. Common messages on motives, aims and procedures • A bright future – more patients can be helped; • All of health care cannot be publicly funded; • A robust economy necessary, allowing for development • Rationalization not sufficient. Prioritizing necessary, ie, setting limits to services; • Priority setting to be based on principles of human dignity, needs/solidarity, cost effectiveness; • A long-term process. All involved. A common methodology. Reciprocal trust necessary.

7. A “Gold standard” analytical tool Adjusted version of The National Model for Transparent Vertical Prioritisation in Swedish Health Care (Carlsson et al 2007) .

8. A4R in the process • Publicity – openness in results • Relevance – internal stakeholders included; entire organisation participating; Gold standard methodology used for analysis • Revision – a learning process; each eventual political decision to be revisable • Enforcement – political will; long-term process

9. 3 stages • Department level priority setting. Identify low priority 10 % of net budget. 2 months. • Intra-departmental priority setting. 10groups/9 members/3 days. Quality revision. Identify low priority items = 4% of group net budget. A fortnight. 3. Political bargaining & decision making. Reallocate 3%.

10. Ideal and reality in stage output Stage 1: Ideal 10 % - Reality 7.2% Stage 2: Ideal 4 % - Reality 3.4 % Stage 3: Ideal 3 % - Reality 2.2% Stage 1: All depts. (­med. services) identified 10% Stage 2: All depts. -1 participated Stage 3: All depts. subject to budget reduction

12. New services funded • Habilitation for children & grown ups (4 MSEK) • Primary care (19 MSEK) COL, Prevention for children & young, Prevention of psychiatric illness and impairment, Palliative care, Coronary care • Psychiatry (24 MSEK) 23 beds, Traumatized refugees, Addiction • Specialized hospital care (29 MSEK) Cancer pain treatment, Coronary care (NG), New pharmaceutics Screening abdomen aorta. • Diagnostics and medical services (12 MSEK) New lab methods, IT-security. • Staff/organization (25 MSEK) New competences, necessary staff and org. development

13. Main net results of prioritisation

14. Results in relation to the ethical template • Better satisfaction of needs among severely ill and those with reduced autonomy – Principle of human dignity • Improvements for the severely ill by reducing services for the healthy or moderately ill – Principle of needs and solidarity • Improving outcome with given resources – Principle of cost effectiveness

15. 1-yr implementation result 84% of disinvestments were implemented, = 74% of expected economic effects

16. Participants’ attitudes Surveys to participants after • Stage 1 (dept level priority setting); Analysis on dept mgrs only; N=95, n=74 (78%) • Stage 2 (intra-dept priority setting); N=91, n=75 (82%) • Process complete; N=166, n=106 (64%)

17. Participants’ opinions 9/10 thought the political decision was feasible and ethically acceptable, partly or on the whole. Many were positively surprised over this, that the decision was taken, and unanimously. New insights about own and other’s services – About the own during stage 1 About that of others during stage 2 Attitudes towards the outcome

18. Identified improvement needs • Better preparation • More efforts on & time used for departmental priority setting • Improve priority setting for service departments • Better coordination between dept & intra-dept priority setting • A new form for identification of services actual for new funding

19. Overall judgement A successful process • A strategy for re-allocation was created • Priority setting was performed • A political decision was made • Economic space for development was created • Resources were allocated • The process was explicit, characterized by taking on responsibility and served as the intended learning process.

20. Success factors • Organizational wish for a strategy for re-allocation from low to high priority interventions • Goal-orientated process • Much effort on reflection before and during the process • Clear process leadership • A thorough communications strategy, integrated early in process and management • Political consensus about procedure and decision making and a strong political commitment during all of the process.

21. More results: Waldau, Lindholm & Wiechel (2010). Priority setting in practice: Participants opinions on vertical and horizontal priority setting for reallocation. Health Policy. http://dx.doi.org/10.1016/j.healthpol.2010.02.007

22. Future use of the dept level method and results, % of respondents

23. New insights from priority setting, %

24. The procedure for intra-dept (horizontal) priority setting

25. Ethical content & feasibility of political decision, %