Session 5.2 – Professional Engagement and Views on Priority Setting
Thursday October 30 15:30-17:00
Managing the Agenda: Professional and Public Engagement in Healthcare Commissioning in England
(Abstract 0075)Madeleine Murtagh, Duika Burges-Watson, Angela Bate, Cam Donaldson
Newcastle University, United Kingdom
Background: National Health Service (NHS) in England has sought to shift the balance of power for healthcare decisions toward the level of the patient resulting in the creation of formalised structures designed to encourage professional, patient and public involvement in healthcare decision making. The PCT Board and Professional Executive Committee are the key formal mechanisms for engaging professionals and the public in decisions about health care commissioning.
Objective: To examine the operationalisation of decision-making structures in one Primary Care Trust (PCT) in the north of England.
Methods: Ethnography and discourse analysis.
Results: Decision making is shaped though a variety of rhetorical strategies that limited the scope of decision making, present a limited role for professional and public members in decision making and in varying ways exclude participants from the decision making process. Professional managers must juggle competing objectives and are accountable or getting the business done; in this case the business of commissioning health services. The task for professional managers is therefore a taxing one; managing unruly Board/PEC members as well as being responsible for operationalising national policy. It is not clear that non-executive members understand the ‘juggling’ work done by the managers and the broader debate, that could potentially unveil these competing objectives, did not seem possible.
Policy Implications: Existing structures for decision making in conjunction with the accountability relations of professional managers may make it impossible to allow genuine engagement of professional or public participants in decision making.
Evaluation of the Swedish National Guidelines as a Tool for Transparent Priority Setting
(Abstract 0017)Peter Garpenby, Per Johansson
National Centre for Priority Setting in Health Care, Sweden
Background & Objectives: In Sweden the provision of the health care service is organised at the regional and local authority level, which means that the state authorities have a limited number of policy instruments at their disposal with which to influence the quality and distribution of services. In 2004, evidence-based national guidelines became a prominent instrument for transparent priority setting in the health service. The implementation of the national guidelines for heart disease has been evaluated in four counties in Sweden.
Method: Ninety-six interviews with politicians, administrators, managers and clinicians from four local authorities in Sweden were carried out in 2004, and 45 interviews in 2007.
Results: The guidelines were primarily implemented at a low level in the organisation, involving senior clinicians and clinical managers. Local authorities with well-functioning medical expert groups took the lead in the implementation process. The guidelines have influenced local treatment protocols, and have been an important focus of discussion in the medical profession at the local level. Nevertheless, the guidelines have not made the county councils’ priority-setting process more transparent or comprehensible for the general public.
Policy Implications: The Swedish national guidelines, developed at central government level, are an example of a policy tool that combines information and exhortation without involving rewards or sanctions. They have not so far succeeded in influencing all decision-makers or the full range of decisions about resource allocation in the local-authority-based health service.
Decision Maker Views on Priority Setting in the Vancouver Island Health Authority
(Abstract 0029)Francois Dionne1, Cam Donaldson2, Jennifer Gibson3, Howard Waldner4
1University of British Columbia, Canada, 2Newcastle University, United Kingdom, 3University of Toronto, Canada, 4Vancouver Island Health Authority, Canada
Demand for healthcare services changes as population and technology change. Adjusting services to this changing demand requires more than individual assimilation of new knowledge; organizational changes are necessary. However, health care organizations typically have no formal mechanisms through which new knowledge can be incorporated into the decision-making process on program funding. Priority setting processes address this shortfall.
An emerging area of interest in the research on priority setting processes for healthcare organizations has been the empirical analysis of the desired characteristics of such processes from the perspective of decision-makers. In this study, we conducted in-depth, face-to-face interviews with 18 senior managers and medical directors with the Vancouver Island Health Authority (VIHA), an integrated health care provider in British Columbia, Canada. Interviews were transcribed and content analyzed and major themes and sub-themes were identified and reported.
Respondents identified nine key features of a desirable priority setting process: inclusion of baseline assessment, use of best evidence, clarity, consistency, clear and measurable criteria, fair representation, effective dissemination of process information, built-in evaluation of results, and alignment with the strategic direction. Existing methods for adjusting the mix of services provided were found to be lacking on most of these features. Respondents also identified and explicated several factors that influence program funding decisions, including political considerations and organizational culture and capacity.
These findings contribute to the developing body of knowledge on contextual evidence pertaining to priority setting processes and, as such, are relevant to settings beyond VIHA.
Significance of Involving Clinicians in Priority Setting
(Abstract 0116)Thorsten Meyer, Heiner Raspe
University of Luebeck, Institute for Social Medicine, Germany
There is no open debate on priority setting or rationing in Germany. Politicians act by budgeting spending, leaving rationing decisions to the clinicians without providing any publicly consented criteria. This is accompanied by a growing alienation of clinicians from political regulatory decisions. In reference to current Swedish approaches we aim to demonstrate how clinicians can be involved into open priority setting, to identify roles of clinicians and politicians and requirements for this process to be successful.
Methods: Historical and systematic analysis of Swedish prioritisation development by document analyses and expert interviews.
Stimulated by the Norwegian Lønning-commission, the Swedish parliament set up a parliamentary commission in 1992 to delineate principles to guide priority setting in health care. These principles, human dignity, need and solidarity, and cost-efficiency, provide the ethical platform for clinical care guideline developments with priority ratings from 1-10 on condition-treatment pairs. These guideline developments are organised by a central government agency (National Board of Health and Welfare), but accomplished predominantly by clinicians. The guidelines provide recommendations; adherence is not a matter of legal but social sanctions. Care provision can be monitored openly by clinical registers.
Within a clinical domain the clinical profession defines their priorities (vertical prioritisation). Politicians have to assume responsibilities for priority setting among different medical domains (horizontal prioritisation). Active engagement of clinicians and provision of open information on medical treatments appear to encourage professionals’ commitment to prioritisation without necessitating legal sanctions. Policy implications for the Germany health care system are discussed.