Journal of Public Health Advance Access originally published online on April 26, 2006
Journal of Public Health 2006 28(2):125-132; doi:10.1093/pubmed/fdl006
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Rationalizing rationing in health care: experience of two primary care trusts
Zafar Iqbal
Zafar Iqbal, Director of Public Health, Public Health, South Western Staffordshire Primary Care Trust, Mellor House, Corporation Street, Stafford ST16 3SR, UK
Alison Pryce
Alison Pryce, Public Health Practitioner (Analyst), Public Health, South Western Staffordshire Primary Care Trust, Mellor House, Corporation Street, Stafford ST16 3SR, UK
Musarrat Afza
Musarrat Afza, Specialist Registrar, Public Health, South Western Staffordshire Primary Care Trust, Mellor House, Corporation Street, Stafford ST16 3SR, UK
Address correspondence to Zafar Iqbal, E-mail: zafar.iqbal{at}sws-pct.nhs.uk
Background Priority setting, or rationing, in healthcare is an unavoidable consequence of competing demands on the resources available. This is a description of the experience of the two Primary Care Trusts in using an explicit scoring tool to prioritize proposals submitted for new funding within the local health economy.
Methods A Priorities Forum Panel was established, comprising representatives from the local NHS trusts. The Panel reviewed and scored new funding proposals and then ranked them for priority funding.
Results Over 100 proposals were submitted (total cost: approximately £44 million). Sixty-six proposals were scored (total cost: over £26 million). Around £5 million was available for funding, resulting in few of the top-scoring proposals being supported. The proposals which were linked to the implementation of National Institute for Health and Clinical Excellence (NICE) guidance were generally given a lower priority compared with those likely to relieve local pressures and facilitate the implementation of specific National Service Framework criteria.
Conclusions Funding of the locally driven priorities took precedence over some of the nationally driven priorities, such as funding of specific NICE guidance. The shortfall in resources did not allow for the funding of a significant number of high-scoring proposals.
Keywords: economics, health services, Priority setting, rationing, NHS funding, NICE funding
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Introduction |
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Healthcare systems everywhere are faced with the problem of limiting the growth in spending on health services, whilst ensuring that their populations have access to appropriate care. Since April 2002, major decisions about what to fund—and therefore what not to fund—have been made at local level by Primary Care Trusts (PCTs).
The most famous attempt to ration medical care explicitly, systematically and openly is the Oregon Health Plan.1 In the UK, approaches to rationing access to treatment have taken a variety of forms including waiting lists,2 guidelines3 and National Service Frameworks (NSFs).
Traditionally, national guidelines were produced by the Royal Colleges and other professional societies. In 1999, the Government established the National Institute for Clinical Excellence (NICE), now the National Institute for Health and Clinical Excellence. Given its role in the review of expensive new health technologies, NICE could be seen as a form of explicit national rationing.4
Local attempts at prioritization have arisen involving the use of various scoring systems.2 This article outlines an approach to priorities setting applied across a local health economy. It is a flexible combination of explicit and implicit criteria—a form of ‘muddling through elegantly’.5
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Methods |
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All local health organizations were invited to identify service cost pressures and submit service development proposals to the Priorities Forum Panel. An overview of the process is shown in Fig. 1.
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The Priorities Forum Panel
The Priorities Forum Panel was established across the two PCTs and three trusts (the major providers of acute, mental health/learning disability and ambulance services) and was chaired by the Director of Public Health of one of the PCTs. The forum ensured that all key stakeholders were involved in the decision-making process and provided the opportunity to debate the merits of competing priorities for limited resources within a structured framework.
Scoring tool
The scoring tool was initially developed by a group representative of local organizations and piloted in 2002/03. It was modified for use for 2003/04. It consists of six key areas: national priorities, local priorities, risk assessment, local needs, effectiveness and cost. It has a minimum score of one and a maximum score of 100. A more detailed description is given in Fig. 2.
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The structured scoring tool was used to give each proposal an agreed priority score. Each organization had two voting panel members; scores were based on a consensus of opinion of the voting members. Proposals were then ranked in ascending order for priority funding from available resources.
The scores were then made available to the Directors of Finance who led the negotiations for the service-level agreements (SLAs) between PCTs and provider units. This article does not describe how SLAs were agreed.
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Results |
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In 2003/04, 134 proposals were submitted to the Priorities Forum for new funding in 2004/05. The total cost of proposals was approximately £44 million. In all, 66 proposals were scored, amounting to a total cost of around £26 million. The remaining were judged by the panel to have provided insufficient information (e.g. not enough information to score one or more of the domains) to be considered for scoring.
A complete list of the scored proposals is given in Table A1. The total scores are shown graphically in Fig. 3. Figure 4 shows the distribution of scores across the submitting organizations.
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Discussion |
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The essential features of this approach are that the process is explicit, structured, transparent and involved key stakeholders. It enabled structured discussions to occur across the health economy, resulting in a common understanding of the most important service pressures. Commissioners were also provided an opportunity to challenge whether all solutions had been considered, including those spanning primary–secondary boundaries. One of the unexpected outcomes of the process was that it engendered partnership working, with the panel directors often arguing for proposals for other sectors against the interests of their own organization. The panel also achieved a remarkable degree of consensus, with only one proposal being scored by a vote.
Although this process used a systematic scoring approach, it comprised a mix of implicit and explicit criteria, and like existing processes is prone to bias by a range of influences such as local political pressures from clinicians or managers. The approach was time-consuming, requiring 10 working days of panel time to score the proposals and numerous hours of staff time in developing and preparing the proposals in the first instance. Another drawback was that the process had no weighting for issues related to wider determinants of health. In addition, the involvement of patients and public was limited to the requirement of proposals, demonstrating adequate patient public involvement before being presented to the panel.
The final total scores indicate that NICE guidance (which is an obligatory requirement for funding)6 was given a lower priority within this local prioritization process, with other pressures on services taking precedence. Issues scoring the highest appear to be the services, which were in some sort of crisis or where non-funding would have led to serious consequences such as service closure.
The results of this exercise demonstrate that not all local and ‘must do’ national pressures can be met within national resource allocation to PCTs, hence the need for prioritization. It also illustrates the financial gap between what is an affordable and what is a desirable level of funding. The process also raised expectations that cannot be fulfilled. Of the £44 million cost pressures submitted to the forum, less than £5 million was available for funding. This also raises the question whether the baselines funding set nationally are adequate to meet even the highest of the priorities.
What is the future role of PCTs in priority setting? Clearly, as resources have been devolved to PCTs, they will remain accountable for priority setting. However, two recent developments further complicate the role of PCTs in priority setting: payment by results (PbR)7 and practice-based commissioning.8 There will still be a role for cross-health economy planning and prioritization but will need to occur in the context of a different set of financial incentives under PbR. In addition, practice-level commissioning could potentially undermine both health economy-wide planning and prioritization, if appropriate systems are not put in place to appropriately engage practices.
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Appendix |
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Acknowledgements |
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The authors thank Dr Roger Beal, PEC Chair, for his input into design and implementation of the process and Anita Wellsbury for her administrative support.
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References |
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- Oberlander J, Marmor T, Jacobs L. The Oregon Health Plan: rhetoric, rationing and reality. Br J Health Care Manage 2001;7:358–62.
- Devlin N, Harrison A, Derrett S. Waiting in the NHS. Part 1—a diagnosis. J R Soc Med 2002;95(5):223–6.
[Free Full Text] - Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. J Health Serv Res Policy 2001;6(3):163–9.
[Abstract/Free Full Text] - Syrett K. A technocratic fix to the ‘legitimacy problem’? The Blair government and health care rationing in the United Kingdom. J Health Polit Policy Law 2003;28(4):715–46.[Abstract]
- Hunter DJ. Rationing healthcare: the appeal of muddling through elegantly (commentary). Healthc Pap 2001;2(2):31–7.[Medline]
- Department of Health. Primary care prescribing and budget setting guidance 2002/03, including text of directions about provision of funding for treatments recommended in appraisal guidance issued by NICE (Item 26). Chief Executive Bulletin (Issue 97), 14–20 December 2001. Available from http://www.publications.doh.gov.uk/cebulletin20december.htm (5 April 2006, last accessed date).
- Department of Health. Reforming NHS Financial Flows: Introducing Payment by Results. London: Department of Health, 2002.
- Department of Health. Practice Based Commissioning: Engaging Practices in Commissioning. London: Department of Health Publishing, 2004.
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