Session 7.3 – Successes and Limits in Priority Setting
Friday October 31 11:00-12:30
What Is Successful Priority Setting and How Can We Measure It?
(Abstract 0013)Shannon Sibbald1, Ross Upshur1, Peter Singer1, Douglas Martin1
1University of Toronto Joint Centre for Bioethics, Canada, 2University of Toronto Department of Health Policy Management and Evaluation, Canada, 3McLaughlin-Rotman Centre for Global Health, Canada
Background: Imagine you are a hospital CEO, concerned about the quality of your priority setting (ps), but having no explicit guidance to do it well; you need a tool to a) provide guidance and b) help you evaluate and improve your decision making. Currently there is little information available to evaluate ps. Research shows decision makers want guidance and are willing to work with researchers.
Objectives: Overall goal, to answer: ‘How can we evaluate success in ps’? Objectives: (1) define success from stakeholders point of view (2) create and pilot test a tool to measure success in ps.
The result of (1) was a conceptual framework with 10 elements germane to successful ps; this was presented at the International Conference in 2006. This presentation focuses on (2).
Methods: (1) Create an Evaluation Tool via an iterative process and psychometric testing. (2) Test the Tool: a pilot test of the tool to determine usability.
Results: The tool contains both procedural and substantive goals of ps, and specifies both quantitative and qualitative dimensions. Psychometric tests show the test has sensibility and the pilot test at a mid-size urban hospital shows the tool is usable by decision makers to evaluate ps. The tool can identify areas of success and opportunities for improvement.
Policy Implications: To our knowledge, this is the first tool to evaluate success in ps. By evaluating, we take steps toward improving, ps and provide guidance and a common language for decision makers nationally (and hopefully internationally) in complex ps.
Is Programme Budgeting and Marginal Analysis (PBMA) the way forward for priority setting in health care?
(Abstract 0126)Angelos Tsourapas, Emma Frew
University of Birmingham, United Kingdom
Background: PBMA is a systematic, explicit priority setting toolkit, which aims to assist decision makers in identifying the most efficient use of resources. There are approximately 80 documented examples of its use, spanning 60 health authorities across the UK, Australia, New Zealand and Canada over the last 25 years. The last detailed literature review on the use of PBMA and the evaluation of the framework was published in 2001.
Objective: To update and extend the above review by reviewing all PBMA publications since 2001 as well as reviewing papers reporting long-term results of PBMA applications, to summarise different reported evaluation methods of PBMA, and to attempt to re-evaluate all applications of PBMA published since 1995.
Methods: Systematic literature review
Results: The search identified 26 cases of PBMA applications published between 1995 and 2007. The success of PBMA was found to depend on several factors: composition of the advisory panel; the level of support provided by the seniors of the organisation; the level of understanding of the current priority setting process; data availability. All these factors represent important challenges for the use and implementation of PBMA in practice.
Policy Implications: Over time PBMA has become recognised as an acceptable tool for priority setting within health care organisations. However, this acceptability is largely determined by the presence of a PBMA champion, either internal or external to the organisation. Without the support from such a champion, the sustainability and success of PBMA over time is open to question.
Primary Care Thirty Years after Alma-Ata: What Have We Learned?
(Abstract 0034)Leto Quarles1, Alexander Ivanov2
1Clinica Campesina Family Health Services, United States, 2American Academy of Family Physicians, United States
In 1978, the International Conference on Primary Health Care met in Alma-Ata, USSR, to formally define, and set as urgent global priority, Primary Health Care (PHC). A call was issued to the world’s leaders in government and in healthcare to bring about Health for All by the year 2000 (HFA2000). Primary Health Care was initially conceptualized not simply in terms of disease and prevention, but more fundamentally as a universal human right based in social, economic and developmental progress and requiring worldwide expansion of education, nutrition, sanitation and peace. The Declaration of Alma-Ata boldly declared that “an acceptable level of health for all the people of the world by the year 2000 can be attained…” Thirty years later, we have allowed this deadline to pass and fallen shamefully short of this lofty goal. Here the authors will analyze social, political, economic and health-outcomes data from individual nations, regions, political/economic clusters, and the world as a whole over the past three decades. We shall retrospectively identify common features of societies which have made the greatest strides toward implementing Primary Health Care and achieving Health for All, so that future policy development can be guided by a better understanding of local and global social, geopolitical, natural and unnatural determinants of health.
When Evidence is Not Enough - Accounting for Politics in Local (Primary Care Trust) Priority Setting
(Abstract 0028)Henrietta Ewart
South Central Priorities Support Unit, Public Health Resource Unit, United Kingdom
Without politics there would be no National Health Service. In the 1980s, politics kept health inequalities off the NHS agenda just as politics has led to their inclusion today. Political process shapes the context within which the NHS operates and those responsible for prioritisation must engage with this.
The need to agree priorities is increasingly acknowledged within NHS policy, for example within the annual NHS operating framework and as a core component of the ‘World Class Commissioning’ professional competencies. Much prioritisation requires local decision-making. However, the founding values of the NHS – that it should be comprehensive, universal, funded from general taxation and free at point of use – do not provide a useful framework for prioritisation at this level.
Primary Care Trusts should be able to account for their local prioritisation decisions in a way which is consistent, transparent and fair; engaging with the political without becoming expedient. This paper argues that the best way to do this is through development of explicit local values, extending beyond clinical and cost effectiveness, which can be used for prioritisation within the context of clear policy and process. The paper includes examples of the ‘local political’ challenges that impact on such a system, including single issue group pressure, fear of adverse publicity, reliance on ill-defined values such as ‘compassion’ etc. and demonstrates how robust values and process can resist these. Based on experience within PCTs, the author discusses factors related to the success or failure of local systems in ‘accounting for politics’.