PRIMARY RESEARCH
Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England Suzanne Robinson*, Helen Dickinson*, Tim Freeman*, Benedict Rumbold† and Iestyn Williams* *University of Birmingham – Health Services Management Centre, Birmingham, UK; †Nuffield Trust, London, UK E-mail:
[email protected]
Summary Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.
Helen Dickinson, PhD MA BA, University of Birmingham – Health Services Management Centre, HSMC, 40 Edgbaston Park Road, Birmingham B15 2RT, UK.
increasingly been reflected in health-care policy. In England, for example, priority-setting has been explicitly embedded in the local commissioning function (whereby services are purchased by Primary Care Trusts [PCTs]) as well as being enshrined in the National Health Services (NHS) Constitution.4 However, while the policy mandate is clear, rather less is known about the manner or extent to which explicit priority-setting is being enacted; the specific mechanisms and processes adopted, the extent of usage of decision-making tools or the range and scope of stakeholder involvement in decision-making. This paper reports findings from a survey of commissioners in the English NHS that aimed to provide a national picture of current priority-setting models and practices. It considers the implications of these findings for the wider challenge of health-care priority-setting.5
Tim Freeman, PhD MSc BA, University of Birmingham – Health Services Management Centre, HSMC, 40 Edgbaston Park Road, Birmingham B15 2RT, UK.
Background
Introduction Resource scarcity is one of the greatest challenges facing public health-care systems with implications for the efficiency, justice and fairness of services. Over the last 10 years, critical commentary has advocated a shift from implicit approaches to priority-setting (such as increasing waiting times and bed-side rationing) towards more explicit, transparent and systematic approaches.1 – 3 This shift has
Suzanne Robinson, PhD MSc BSocSci, University of Birmingham – Health Services Management Centre, HSMC, 40 Edgbaston Park Road, Birmingham B15 2RT, UK.
Benedict Rumbold, PhD MA BA, Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK. Iestyn Williams, PhD Mphil BSocSci, University of Birmingham – Health Services Management Centre, HSMC, 40 Edgbaston Park Road, Birmingham B15 2RT, UK.
The current context of economic austerity means healthcare decision-makers are under renewed pressure to consider priorities around investment and disinvestment. Historically, public systems struggle with decommissioning (i.e. ceasing to provide services),6,7 and therefore
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improving priority-setting processes is likely to become increasingly important as health-care organizations are subject to greater fiscal scrutiny and constraint. Governments’ response to the continued demand and financial pressure on publically funded health-care systems has been to develop more systematic evidence based decision-making processes.1 – 3 The Oregon experiment, which attempted to draw up a list of priorities for Medicaid in the USA, is probably one of the earliest attempts to take a more explicit approach to priority-setting.8 The shift towards more explicit prioritysetting has seen the development of a number of technical approaches, with approaches such as economic evaluation becoming more popular over recent years.9 Priority-setting is a politically charged activity and politicians in most countries have distanced themselves from making resource allocation decisions by delegating and/or devolving responsibility to meso-level agencies or professionals working at the front-line of service delivery.3 Since the 1990s, there has been a move to priority-setting by guidelines, rather than exclusions, and a number of Health Technology Bodies (HTA) such as the National Institute of Health and Clinical Excellence (NICE) in England and Wales, and the Institute for Quality and Efficiency in Health Care in Germany have been setup to provide guidance to decision makers in relation to the adoption of new technologies.10 More recently, a number of HTA bodies have also started to provide evidence and guidance in relation to the withdrawal of low value technologies. Klein11 suggests that such bodies are developed to ‘depoliticize decisions about who should get what, NICE was intended to be a technocratic chastity belt to protect the NHS against ministerial meddling’ ( p. 2). However, there is a growing acceptance that technical solutions – such as those provided by NICE – will not solve the priority-setting conundrum and there is a concomitant requirement to strengthen the institutional basis of decision making.11 From this perspective, the development of transparent and accountable decision-making processes that allow for public preferences is important to both strengthen and legitimize decision making.11,12 A number of countries have turned their attention to developing priority-setting processes that are more transparent and open in their decision making.10,13 In this context, the challenge faced by the decision makers is to improve the technical dimensions of decision making, while developing processes that can combine these technical aspects with meaningful involvement of all relevant stakeholder groups, including the public.2,3 There are therefore three key areas of importance for the development of priority-setting: the design of decisionmaking mechanisms and processes (i.e. the ‘model’ adopted); the application of evidence and decision-making tools, and generation of meaningful and appropriate stakeholder involvement. In relation to mechanisms and processes there remains disagreement with regard to the level at which to set decision-making functions and how wider systems and processes should be linked together. However, there is increasing acceptance that ‘fair’ Health Services Management Research
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processes – for example, as encapsulated in the Accountability for Reasonableness framework – are important.12 A number of decision-making tools and information methods have been developed to help in generating evidence-informed priority-setting; these include needs assessment, health-technology assessment, programme budgeting and marginal analysis (PBMA) and multi-criteria decision analysis.14 – 18 In contrast, the literature on which parties should be involved in prioritysetting; remains somewhat under-developed, especially concerning the involvement of citizens and their input with regard to social values.19 In light of these themes, our research aimed to establish how PCTs have addressed these areas of concern. The research was therefore designed to identify the following:
† The design and scope of existing priority-setting arrangements;
† The extent of use of evidence and decision tools to inform decisions;
† Stakeholder involvement in and influence on decisionmaking. The focus for the study was on population-based decision-making and as such does not cover PCT processes for taking decisions over funding treatment for individual patients.
Methods The study comprised a census survey of all 152 English PCTs undertaken between February and March 2010. A survey was designed and developed in consultation with national commissioning experts and a group of NHS commissioning managers, and comprised a series of tick boxes, attitudinal questions and areas for free text responses to capture any additional respondent views. The survey focussed on the following broad themes:
† Formal priority-setting arrangements; † Involvement in priority-setting; † Tools and processes used to aid decision-making; A copy of the survey can be obtained from the authors on request. The survey was distributed electronically to all PCT Directors of Commissioning (or equivalent posts) for all English PCTs. In order to gain responses from as many PCTs as possible, the survey was sent to all commissioning leads where we could not identify a single responsible person. The returned data were transferred into Excel for ease of analysis. Descriptive statistics are used in this paper to report quantitative responses. In cases where more than one individual from a PCT has completed the survey, the data were collated so we had organizational-level data. If the question was a Likert-scale statement, the average score was calculated giving a single score for each PCT. For the dichotomous data (i.e. yes-no type responses), the data were checked for consistency. Where there was any divergence in responses from PCTs, respondents were contacted for clarification.
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Free text responses were coded according to emergent themes, deducted from the literature and reported alongside quantitative data to assist in terms of explanatory power of these findings. For more details of methods and data collection, see reference.5
Results A total of 121 individuals from 80 of the 152 PCTs (53%) completed the survey, meaning that in some PCTs more than one response was provided. In addition to the 80 PCTs that responded to the survey, a further 25 (16%) declined to take part, leaving a total of 47 (31%) nonresponding PCTs.
Design and scope of priority-setting arrangements The majority of respondents (69, 86%) indicated that their PCT’s have instituted formal priority-setting boards (Table 1) that operate predominantly at the PCT level (56, 70%), with five (6%) operating at the strategic health authority level. Only five (6%) respondents indicated that they have boards working in collaboration with other PCTs and three (4%) have boards that operate at the local authority level. However, more than half of the respondents were aware of other priority-setting groups within their local health economy, including local authority groups, children’s trusts and other PCT prioritysetting boards. The degree to which priority-setting processes join-up across health economies (and across individual PCTs) was seen as a concern by a number of respondents. Several individuals expressed anxieties that priority-setting processes were insufficiently comprehensive across providers and pathways, and different priority assessments are being used across different commissioning streams. The respondents also voiced concern about the lack of accountability and authority of their prioritysetting boards, which they saw as contributing to poor rates of decision implementation.
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Changes to priority-setting processes Over half of the respondents indicated that they had made changes to their priority-setting processes in the last three years (Table 1). These changes typically involved the introduction of scoring mechanisms or decision– making tools and the development of more structured decisionmaking processes. Many comments were made in the free text sections about how changes were intended to make processes more ‘comprehensive’, ‘formalized’ and ‘explicit’. These comments mirror what respondents saw as being strengths of their priority-setting processes which tended to relate to qualities of consistency, clarity and rigour. Many respondents conveyed pride in processes that they considered to be increasingly ‘transparent’, ‘visible’, ‘simple’, ‘rational’ and ‘impartial’. For example ‘Three years ago there was no explicit priority-setting process. We now have one as we realized we had to have a transparent defensible process to cope with the changed financial position.’
Sixty-two (78%) respondents reported that their prioritysetting decisions related to ‘new developments’, 48 (60%) stated that their decisions related to non-core budget treatments and 49 (61%) stated that prioritysetting included decisions on core spend. Thus, most respondent PCTs had made efforts to put in place formalized decision-making structures around most areas of spend. However, 80% of PCTs who suggested that their priority-setting boards make decisions on most or all areas of spend also indicated that in reality boards had focussed more on developing robust processes around new service developments than other areas. The free text response below is one such example ‘Our priority-setting board was set up to make decisions on all aspects but in reality its focus is really on new investment and getting it right there.’
Approximately half of the respondents suggested that this focus resulted in decisions only being made ‘at the margins’, rather than across the whole spend, echoing
Table 1 The scope of priority-setting processes
Yes (n)
Survey question
Does your PCT or local health economy have a formal priority-setting group or 86% board? Has your PCT made any significant changes to its priority-setting processes in the last 50% three years? Does your PCT have a dedicated information resource (i.e. information analyst) 51% which supports its priority-setting process? Disinvestment Has your PCT made what you consider to be any significant ‘disinvestment’ or ‘decommissioning’ decisions in the last three years? Did the PCT re-invest all or part of the resources back into the same service area? Did the PCT re-invest resources across service areas? Did the PCT use resources to fund other activity such as service debts?
Do not know/ Nonunsure (n) response
No (n) (69) 14%
(11) –
(40) 14%
(11) 13% (10) 23% (19)
(41) 24%
(19) 11% (9)
14% (11)
54%
(43) 20%
(16) 8%
(6)
19% (15)
29% 9% 16%
(23) – (7) – (13) –
– – –
– – –
– – –
– – –
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–
–
– – –
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results reported in other studies.18,20 A number of respondents indicated that more needed to be done to set priorities around core spend and disinvestment. However, the respondents also noted the limited autonomy of PCTs and the pressure of government policy and centrally mandated ‘must dos’ which limited their ability to focus on prioritizing core spend.
Disinvestment and decommissioning of services A section of the survey dealt specifically with disinvestment decisions. A total of 65 (81%) of PCTs who took part in the survey responded to this section. Just over half of those respondents (43, 54%) suggested that their PCT had made a significant disinvestment decision in the last three years (see Table 1 for further details). Twenty-three respondents stated that the PCT had re-invested all or part of the resources back into the same service area, while seven had re-invested across service areas and 13 (16%) had used savings to fund other activity such as service of debts. In the free text responses, only a small number of respondents suggested that they had actually made a decision to disinvest (i.e. to withdraw or stop spending on a service). Instead, most had re-designed pathways and services thereby disinvesting to re-invest in a disease or service area. Twenty-seven percent of the respondents also mentioned embarking on decommissioning strategies in acute care, for example moving from hospital- to communitybased services. Table 2 gives examples of the types of responses made by the respondents. Overall, disinvestment was considered a weakness in the priority-setting process. As one respondent noted: ‘Not really well developed no clear rational or evidence base for making difficult decisions around disinvestment.’
Table 2 Disinvestment activity Disinvestment and decommissioning services
Disinvest to re-invest
† Decommissioning of † Accident and Emergency and centralization of non-elective acute hospital services on fewer sites
† Disinvestment in the † following series: homeopathy or complementary medicine, and currently considering in vitro fertilization † Closure of an ineffective † community hospital † Policy to disinvest low-benefit † procedures †
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Personal medical services contracts and enhanced services have been re-commissioned and the savings re-invested in other targeted areas within primary care Shift from bed-based service models to community-based models, and to investing in earlier intervention Re-invest in prevention and health inequalities Re-design of stroke and end-of-life services to be more effective Early discharge of people from hospital to assessment units to reduce premature placement in nursing homes
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The responses suggest that the problems associated with disinvestment resulted from a limited evidence base and difficulties in stakeholder engagement ‘we lack a good evidence base to support disinvestment work always harder to dis-invest. Stakeholders don’t want to engage in that especially acute and you need ‘buy in’ from providers and public if you want to dis-invest.’
Cross-tabulation of the data suggest that respondents who reported less developed disinvestment processes also tended to report difficulties with wider stakeholder engagement. A number of these respondents suggest that there needs to be a more system-wide approach to priority-setting and greater engagement with clinicians.
Decision-making tools and information The respondents were asked to rate their views on extent of usage of evidence using a scale of 0 – 0, with 0 representing ‘evidence plays a limited role’ through to 10 which indicates ‘evidence is key to informing decisions’. The majority of respondents indicated that evidence played an important role in decision-making, with 57 (71%) of PCTs rating the role of evidence-based practice as seven or above. The respondents were also asked to indicate the extent of usage of specific forms of evidence and decision-support tools. The main source used to inform investment and disinvestment decisions was found to be epidemiological data (77 [96%] and 56 [70%], respectively), with PBMA tending to have the lowest usage rate for both decision types. The level of usage of decision tools was lower for disinvestment decisions than for investment decisions. See Table 3 for a full break-down of results. The use of evidence from a range of sources was seen as important to effective priority-setting. However, around half of the respondents (38, 48%) highlighted the difficulties involved in benchmarking and finding sufficiently accurate evidence to inform decisions. Free text responses indicated that there was a lack of high-quality evidence to inform decisions and a lack of skill and capacity to collect and interpret information. As one respondent notes ‘There is limited local evidence available and worse than, that we don’t seem to have the right skills in place to identify and analyse information.’
The respondents were asked to rate their perceptions of the influence different decision tools had on investment and disinvestment decisions. The scale ranged from 0 representing ‘no influence’ to 10 representing ‘very influential’. The results suggest that the epidemiological data used in needs assessment (average score 7.51) was the most influential for investment decisions. A review of economic data (average score 7.07) were the most influential for disinvestment decisions. With the exception of local economic data, all scores for tools used for disinvestment were slightly lower than those used for investment decisions (see Figure 1 below).
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Table 3 Different types of tools and processes used for investment and disinvestment decisions Disinvestment decisions
Investment decisions Tool/process
(n)
Epidemiological data (e.g. needs assessment) Predictive modelling Review of local economic data Programme budgeting Programme budgeting and marginal analysis Other decision support tools (e.g. Portsmouth tool and paired tool)
These findings suggest that there are a number of different priority-setting tools and processes being utilized around the country. Most PCTs reported undertaking some form of needs assessment. Beyond this there was less commonality with regard to the tools and techniques employed. Given that none of the tools or processes of priority-setting were seen to be overwhelmingly influential in making decisions, it is interesting that the majority of respondents to the survey felt that their PCT was strong in using evidencebased practice to support their priority-setting decisions. We sent the survey to commissioning leads and it may have been in their interest to respond in a positive manner to this question, and clearly other stakeholder perspectives may vary. The degree to which decisions are perceived to be evidence-based is also interesting, given that only just over half of the respondents indicated that they had dedicated information sources available to support their priority-setting activities. A quarter did not have these types of resources and over eight (10%) respondents were unsure whether they had dedicated information support (Table 1). It is a rather stark finding that a substantial number of the PCTs that responded do not have information support readily available to support their prioritysetting processes. For some respondents ‘having strong
96% 76% 73% 64% 33% 45%
(n)
(77) (61) (58) (51) (26) (36)
70% 66% 56% 49% 25% 25%
(56) (53) (45) (39) (20) (20)
information support is a key ingredient of successful priority-setting’.
Stakeholder involvement in decision-making The picture in terms of stakeholder involvement is again one of complexity and variation. More than 20 stakeholder groups were seen as having some level of formal involvement within PCT decision-making processes. Unsurprisingly, those deemed to have most influence tended to include the Director of Public Health, the chief executive, the PCT board and professional executive committee and commissioning managers, etc. Those considered to have less involvement included partner agencies, provider organizations, service users and the wider population (Figure 2). Perceptions of the value of stakeholder involvement varied markedly. Thirty-seven (46%) respondents believed stakeholder involvement was important, indicating frustration with the lack of meaningful involvement with wider stakeholders, especially the patients and wider public. In contrast, 12 (15%) of them argued that attempts to involve too many stakeholders got in the way of effective decision-making. Although 28 (35%) respondents perceived stakeholder engagement to be a strength of their PCT’s priority-setting processes, on closer inspection
Figure 1 Average respondent rating of the influence different tools and processes have on investment and disinvestment decisions
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Figure 2 Stakeholder involvement
such engagement typically related to clinicians, GPs and practice-based commissioning groups – with local authorities, the general public and service users largely uninvolved. These findings may be a result of the fact that most PCTs were still in the early stages of developing prioritysetting processes. Decision-makers may have been concentrating on sorting out organizational structures and demonstrating that their processes are transparent and accountable, before thinking about how more inclusive and deliberative aspects could be incorporated. There is also the possibility that stakeholders such as the general population and service users scored less highly because the question was framed in terms of ‘formal involvement’.
Focus on new developments The fact that the majority of formal priority-setting activities focus on new developments and investments, but less around decisions on core treatments, is the result of a combination of factors including the low base from which PCTs are starting in terms of commissioning and their limited autonomy to make decisions. As Smith et al. 21 remind us, ‘PCTs are constrained in how they operate, being subject to direct performance management by Strategic Health Authorities and the Department of Health, having to keep within a specified budget annually, possessing no potential to retain savings and invest for future use, and having lower access to capital for investment’.
Tools
Discussion In this section we reflect on the findings in relation to the three areas set out in the background with respect to the existing literature and also explore the implications for the wider field of priority-setting. From this we hope to set out the existing state of knowledge and identify areas for future development.
Decision mechanisms and scope Our results suggest that there are a number of distinct priority-setting arrangements in operation across England. This raises the question of consistency: are arrangements well coordinated across local regions or are there too many ad hoc bodies that operate in isolation from one another? The ideal scope and coverage of priority-setting bodies is a topic of long-standing debate.1 In this study, a number of respondents voiced concerns about the degree to which priority-setting processes join up across health economies. More in-depth research is required to further explore the remit and scope of local priority-setting activity. Health Services Management Research
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Although it is clear that there are a number of different priority-setting tools being utilized, what is less clear from our research is how these were being used and the extent to which they shaped decision outcomes. This latter factor is currently contested within the literature, with some commentators suggesting that tools such as PBMA are instrumental in successful priority-setting, while others claim that technocratic approaches merely serve as legitimating devices.11,22,23 Some of the concerns expressed about priority-setting processes were around the inability to find a tool that would give the ‘right’ answer. However, the intention behind many decision tools is to aid the decision process and allow for a more deliberative, transparent decision, rather than to come up with a ‘final score’.17 Further, using such techniques may help with stakeholder engagement and gain wider support for resource allocation decisions.
Involvement In line with previous experience, the main concern of decision-makers was to gain organizational support
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with patients and public considered secondary.24,25 Engagement strategies, both formal and informal, concentrated on stakeholders from within the PCT and from other health-care organizations perceived to be important to the process. In contrast, little energy was directed towards involving or seeking support from more remote stakeholders such as local government, patients and the public. Whereas this may reflect a pragmatic approach, other research suggests that there are strong arguments for opening up priority-setting to wider input, not least in generating legitimacy for such a contentious area of health-care decision-making.26 Commentators argue that legitimization of resource allocation decisions depend on the institutions of public involvement and focus on procedural justice.11
Implications for the wider field of priority-setting This study has implications for the wider field of prioritysetting that has become a preoccupation of health-care systems throughout the world. A number of features of the PCT model are of interest, including: the attempt to adopt an explicit, evidence-based approach; the location of primary responsibility for priority-setting within the commissioning function and the decentralization of responsibility for how priority-setting is achieved by local commissioning bodies. Each of these is briefly reflected upon in this section. At the surface level, our study confirms previous assertions of the value of taking an approach to prioritysetting that is informed by application of both evidence and decision tools.14 – 16 This can be seen in the prevalence of these in responses which, not withstanding caveats around data reliability, show significant increases when compared with previous studies.18 What is less clear from the study however, is how these techniques were employed and whether their inclusion constitutes a significant shift towards explicit decision-making. The notable lack of progress in opening decision-making up to wider input and scrutiny (for example from the public) points to a possible reluctance to fully embrace an explicit approach. This leaves PCTs open to the accusation of using evidence and decision tools primarily as a legitimizing device rather than as a driver of decision outcomes.22 – 24 Therefore, we would argue that more evidence is required to demonstrate that PCT activity represents a genuine step-change in practice compared with previous arrangements and practices observed in other settings. Our study is inconclusive with regard to whether or not commissioning is the optimal location for the prioritysetting function, much less whether a market-like context provides the correct levers for implementation of a local prioritization strategy. However, many of the reportedly more successful arrangements appeared to be based more on a model of collaboration and shared decision-making, than on the notion of the commissioner as managing a competitive provider market. Overall, the study suggests that the success of priority-setting is likely to be heavily
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dependent on the effectiveness of the wider commissioning role in shaping and overseeing local delivery systems. Furthermore, we would argue that attention needs to be paid to the role of non-commissioning bodies in prioritysetting – not least the extent to which ‘implicit’ rationing at the bedside continues to be practiced as a means of managing stretched provider budgets. The study took place against a backdrop of a changing health-care landscape and many respondents indicated that instability and uncertainty at the national level had hindered their attempts to implement local systems and processes. A common theme expressed was the perceived failure of national government to provide a narrative of resource scarcity that would help legitimize unpopular local decisions. This tension between national rhetoric and local budget constraints is not new and indeed may not be entirely resolvable.24 The changing status of NICE guidance on technology coverage is perhaps symptomatic of the pitfalls associated with either centralizing or devolving the decision-making function in health-care prioritization. Overall, however, our study suggests that the ideal blend between national and local decisionmaking – as well as between standardization and variation from area to area – had not been struck.
Study limitations The survey responses presented here provide a crosssectional view of perceptions and practices concerning priority-setting in the English NHS. The response rate to the survey compares well to similar, unsolicited surveys of this type,27 with more than half of PCTs providing detailed information about their priority-setting activities. While the response rate was generally good, it is possible that response bias could have been introduced due to nonresponse. However, the characteristics of the responders in terms of PCT size, index of multiple deprivation score and proportion of population under 75þ demonstrated a fairly even representation of these characteristics at least. Further, limitations include the fact that we only captured self-reported perceptions of local commissioners. Whereas individual perceptions are important, they may not always reflect actual practice or indeed wider health economy views on a topic. Survey methods are limited in terms of the depth of information that can be obtained. Whereas we did allow for qualitative responses alongside categorical responses, this did not allow for probing and clarification in the same way that face-to-face discussion does. The second phase of the research used qualitative research methods to undertake a more in-depth analysis of local priority-setting (further details can be found in the main research report).5
Conclusions The English ‘experiment’ in PCT priority-setting does not, as yet, appear to have resolved the difficulties and tensions associated with introducing explicit priority-setting into contemporary, large-scale health-care systems. Whereas Health Services Management Research
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Box 1 Key headlines and lessons from survey
† †
† †
†
†
† † †
The picture of priority-setting across PCTs is one of a complex patchwork of different approaches and tools being adopted. Most PCTs have some form of formal process in place, but these have predominantly been geared around whether to introduce new developments and/or focussed on how to spend additional money, rather than around core budgets and disinvestment. PCTs employ tools and processes that are devised to deal with economic, ethical and management aspects of priority-setting. Frustrations were expressed that decisions tend to be ‘made at the margins’, rather than in relation to the ‘core spend’ and across the whole commissioning strategic plan’. Much of the focus of PCTs seems to have been in creating ‘rigorous’, ‘transparent’ and ‘accountable’ processes at the level of the PCT, but less has been placed on deliberative and widespread, inclusive and meaningful stakeholder involvement across the health economy. Concerns were raised about the ‘join up’ across health economies, with priority-setting processes being described as insufficiently comprehensive across providers and pathways, with different priority assessments being used across commissioning streams. A substantial number of PCTs did not have information support readily available to underpin their priority-setting processes. Stakeholder engagement tends to be in terms of clinicians, GPs and practice-based commissioning groups rather than local authorities, the general public and service users. Relationships with the local population seems to be more related to information sharing than meaningful engagement, although many respondents noted that the new statutory responsibility to engage with the public would mean that this would become an important focus going forward.
good practice has arguably been developed, there remain a number of points of tension and shortfalls. In particular, attention is required to how best to allocate responsibility for priority-setting, how to ensure that priority-setting ‘on the margins’ becomes a more embedded approach to budget management and how a genuinely explicit, inclusive approach can be fostered. Box 1 outlines the main headlines and lessons from the national survey.
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