Empirical evidence of systematic approaches to priority setting

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Empirical evidence of systematic approaches to
priority setting

• Presentation prepared for ESRC Seminar Series
• Managing Scarcity in the NHS Building on theory,
  learning from practice
• December 1, 2005
• Iestyn Williams,
• Health Services Management Centre, University of
  Birmingham
• Oya Asim,
• National Perinatal Epidemiology Unit (NPEU),
• University of Oxford

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Purpose

• Use of systematic approaches to managing resource
  scarcity at the local level
• Two independent empirical studies
• 1) Technology coverage committees
• 2) PCT level

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Technology coverage committees and Cost
Effectiveness Analysis

• Iestyn Williams
• HEF/HSMC
• University of Birmingham

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Research objective

• Started out as
• to explore usage of CEA in macro and meso
  policy decision making
• But became a more upstream exploration of the
  role and functions of these decision making
  bodies

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Methods

• Survey/ technology request forms
• Case studies
• Selection
• Multiple methods
• Workshops

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Role and purpose

• Formulary management
• Introduction/inclusion of new techs
• Representative membership
• Information support
• Technology appraisal?
• Evidence based policy?

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Variation

• Remit
• Geography/sector/organisations
• Finance
• Clout
• Resources
• Stated decision methodology

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Use of Cost Effectiveness Analysis
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Requesting
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Requesting

• Is there evidence that this proposed new
  treatment is more cost-effective than standard
  treatment already in use? Yes. No.
• Does this drug provide good value for money?

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Accessing

• Im just racking my brain to try and think of a
  situation where weve had an economic evaluation
  and I dont think we have actually, to be
  honest.
• The big problem is that most of the applications
  we get for drugs are at the time they are first
  launched and such data really doesnt exist at
  that point other than guess-timates from the drug
  companies.

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Interpreting

• Could I sit and describe to you precisely what
  modelling went into a QALY? No Its a bit like
  yes, I can tell the time, but Ive no interest in
  knowing how a watch works.
• You probably need a full-time pharmacist to do
  this properly, linked to a drug information
  centre with critical appraisal skills. We dont
  have that, and couldnt make the case to.

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Implementing

• Structural barriers
• a lot of the economic data looks at savings
  which cant be realised
• Ethical barriers
• if it were perceived that the committee was
  putting a very heavy emphasis on cost rather than
  effectiveness or innovation that would be viewed
  in a negative light

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Role and purpose revisited

• EBP and local contingencies (Jenkings and Barber,
  2004)
• HTA, restricted introduction and expenditure
  control (a continuum)
• Rationing and disinvestment
• Is CEA a useful tool in this context?

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Conclusions

• Decision-making committees need
• clear and agreed objectives leading to improved
  accountability
• Closer or clearer links with finance functions in
  their organisations
• systematic processes by which decisions on
  technology coverage are made
• clearer roles for committee members
• an ability to recall precedents that have been
  established
• consideration of the full impact of their
  decisions

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The PCT level

• Oya Asim
• NPEU,
• University of Oxford

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Background
PCT (board and exec. committee)
responsible for evaluating commissioning txs and
services for a service area
Commissioning group
Service managers
PCT managers and network managers
GPs
Hospital doctors and nurses
Hospital managers
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Design of study (1)

• Observation of 12 commissioning group meetings
• Type of decisions being made
• Role of decision makers
• Context and process of decision-making
• In-depth interviews with members of group
• GPs (2), PCT managers (8), service managers (2),
  hospital managers (3), network managers (2),
  hospital doctors and nurses (2)
• Analysis of documents brought to/used in meetings

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Design of study (2)

• Workshop
• January 2004, 2 hrs, 10 members of group
• Delivered by an experienced health economist
• Format
• Economic concepts
• Economic evaluation
• Systematic approach to priority setting
• Exercise for discussion on prioritising

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Priority setting

• Commissioning group has a key resource allocation
  role decision-making from the ground
• Decisions on
• Investment into new equipment or new staff (to
  fulfil Govt. policy)
• Place of care (community versus hospital)
• Members agree on priorities for funding and
  present their recommendations to the PCT

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Priority setting

• Systematic approach not adopted by the
  commissioning group
• Options appraisal did not consider rigorous
  assessment of costs and benefits and was only for
  new programmes for part of service delivered by
  Trust
• No consideration of disinvestments that might
  need to be made to fund investments (despite
  financial deficit)
• Most decisions eventually funded by PCT (at
  expense of what?)

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Use of economic evaluation
It is a great source of sadness. The only
process where I know economics is being used is
in the NICE process. Everything else is,
frankly, opinion and consensus and policy.
(Public health director)
I remember the days when all Health Authorities
were going to start using health economics to
make their decisions. But we here have not been
in a position actually (Chief executive of PCT)
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Barriers to use (1)

• Acceptability usefulness given conflicting bases
  for setting priorities
• a) National targets
• It seems to me that the prioritisation during
  the workshop came in line with entirely what the
  Government were putting forward and forced us to
  ignore all the other important issues.
  (Clinician)
• b) Different perspectives
• Responsibility for societal decision-making
  unclear clinicians bring their own perspective
  of focusing on the individual patient
• My job is to outline what the case of need is
  for the service and for patient
  care...irrespective of whether they tell me
  theres no money. (Nurse)

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Barriers to use (2)

• Accessibility Understanding of method and
  ability to apply it
• a) Difficulty in comparing different programmes
  with diverse outcomes
• The request for a scanner thats going to cost
  half a million pounds against the requirement for
  a couple of secretaries. (GP)
• b) Difficulty in understanding outcomes measures
  such as QALYs
• Patient quality of life rather than more
  absolute health outcomes.
• (Service manager)
• I dont know much about quality of life
  indicators, I wouldnt be able to apply it.
  (Service manager)

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Workshop

• The workshop was seen as useful
• There were a lot of things I never appreciated
  beforethe whole economics part of it. (Trust
  manager)
• The concepts that came out were not new to me,
  but they were very clearly new to others. At
  first I thought they were going to dismiss a lot
  of it and say, This is common sense, we know all
  of this, but I think several of them hadnt
  realised that there was a systematic and almost
  learned approach (Chair of group)
• Priorities for funding could not be agreed upon
  the exercise was never completed
• No change in decision-making following the
  workshop

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Proposed solution

• Criteria for deciding priorities
• Consider
• Opportunity cost
• Scarcity
• Criteria?
• Groups must feel accountable
• Need for a set budget

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Conclusions

• Awareness of the need to prioritize should be
  strengthened
• Scarcity and opportunity cost need to be
  reinforced
• Workshops might be useful in opening the eyes
  to methods of economics, but need for framework
• Typical economic evaluation has limited practical
  use
• A) Not generally relevant to decisions being made
• B) Unclear societal decision maker

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Common themes emerging from the two studies

• Systematic and explicit priority setting rare
  especially incorporating CEA
• Why?
• Difficulties in generating, understanding and
  applying results of analyses
• An unreceptive context incentives, interest
  groups, ethical-political debate
• Greater systematisation may not involve increased
  use of CEA at local levels

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Contact details

• Iestyn Williams
• Health Economics Facility/Health Services
  Management Centre
• University of Birmingham
• 40 Edgbaston Park Rd
• Birmingham
• B15 2RT
• UK
• E-mail i.p.williams_at_bham.ac.uk

• Oya Asim
• National Perinatal
• Epidemiology Unit (NPEU)
• University of Oxford
• Old Road Campus
• Oxford
• OX3 7LF
• UK
• E-mail oya.asim_at_npeu.ox.ac.uk