Setting priorities for health: Views of Directors of Public Health

1
Setting priorities for healthViews of Directors
of Public Health

• Dr Adrian C Brown
• Specialist Registrar Public Health

2
Context to study

• Where is it most effective to set priorities
• Locally or Nationally?
• Health Reforms since 1999
• Increase freedom to local health communities
• But, nationally created and monitored standards
• Standards particular emphasis on speed and
  equality of access
• Concerns of commentators prior to study (e.g. HS
  Committee)
• Too many onerous national targets
• Attention to target areas at expense of other
  initiatives, (e.g. Public Health)
• (little robust evidence for this as yet)

3
Context to study

• Shifting the Balance of Power April 02
• Further increase in local autonomy
• Development of PCTs performance managed by
  Strategic Health Authorities
• But were local PCT structures adequate to
• identify local health needs?
• prioritise effectively on cost and
  effectiveness?
• plan with consistency avoiding diversity of
  quality?

4
Context to study

• Previous NICE Survey
• Directors of Public Health former Health
  Authorities in 2000
• Impact of NICE on their local health communities
• Identified concerns - balance between providing
  resources for NICE technologies and local
  priorities
• (Views of Directors of Public Health about
  NICE Appraisal Guidance results of a postal
  survey. Davies E, Littlejohns P. Journal of
  Public Health Medicine 200224319-325)

5
Methods

• 1.Study Design
• Questionnaire all DsPH of PCTs in England Spring
  03
• Sections
• Priority setting in PCTs and formulation of the
  Local Delivery Plan (LDP)
• National priority setting
• Influences on local priority setting and
  competing effects of national work programmes
• Categorisation of foregone priorities

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Methods

• 2. Questionnaire Design
• Semi-structured interviews
• Pilot questionnaire
• Revised sent to all PCT DsPH in England
• 3. Participants
• Determined that in May 03, 263 (87) of 303 PCTs
  had a DPH in post - taken as denominator
• 4. Analysis
• Quantitative data - SPSS,
• Qualitative data - Thematic analysis of free text
  comments

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Results

• 1.Return Rate
• 188 of 263 (72) of DsPH in post in May 2003
  (62.0 of all PCTs)
• 2.Profession
• 78 Consultants
• 18 Specialists
• 4 Other professionals/No information

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Results
Section I Priority Setting in PCTs and
formulation of the Local Delivery Plan (LDP)
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Results
What arrangements are in place for identifying
local priorities for your PCT?
n187
10
Results
If a specific group has been formed to identify
local priorities, which PCTs does the work of
this group cover?
n67
11
Results
What methodology is used to identify local
priorities for the PCT(s)?
n187
12
Results
In practice for your PCT is the identification
of local priorities discreet from the production
of the LDP
n187
13
Results

• Which people in the PCT are involved in
• Identifying local priorities
• Formulation of the LDP
• Local negotiation and approval of the LDP?
• Chief Executive, DPH, Medical Director,
  Commissioning Manager(s), Patient
  Representatives, Others
• Chief Executive Commissioning Managers are
  involved across the priority setting process
  DPHs are more involved in identification
  patient reps were involved in identification in
  approx half of PCTs only. The majority of PCTs
  did not have a distinct Medical Director (n187)

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Results

• Which partner agencies are involved in
• Identifying local priorities
• Formulation of the LDP
• Local negotiation and approval of the LDP?
• Local Authority, Social Services, Local Acute or
  Mental Health Trusts, Regional Tertiary/Secondary
  Providers
• The local Acute/MH Trusts are most involved
  partners throughout process. LA are mainly
  involved in identification only (n187)

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Results
Section II National priority setting
16
Results
How important an influence do you believe the
following factors currently actually have on
national priority setting?

• Clinical need
• Population need
• Clinical effectiveness
• Cost effectiveness
• Opinion of prof bodies
• Public opinion
• National political influence
• Media coverage
• HR and logistics
• Inequalities in health
• Inequalities in access

• Of over-riding importance
• Very important
• Of some importance
• Of little or no importance
• No view.
• 97 completed question in full

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Results
Of over-riding importance or very important
18
Results
Of over-riding importance or very important
19
Results

• Rank national work programmes in order of
  priority you personally feel they deserve
• priority you believe currently given nationally
  in the NHS

20
Results
Section III Influences on local priority setting
and competing effects of national work
programmes
21
Results
How important an influence do the following
factors currently actually have on local priority
setting for your PCT?

• Clinical need
• Population needs assessment
• Published evidence on clinical effectiveness
• Published evidence on cost effectiveness
• Historical configuration on services
• Local public opinion
• Internal politics of local NHS organisations
• Demands of local professionals
• Lobbying of special interest groups
• HR and logistics
• Inequalities in health
• Inequalities in access

• Of over-riding importance
• Very important
• Of some importance
• Of little or no importance
• No view.
• 97 completed question in full

22
Results
Of over-riding importance or very important
23
Results
Of over-riding importance or very important
24
Results
To what extent do you feel that national work
programmes have displaced local priorities?
n 183
25
Results
Rank the following national work programmes in
relation to how much you feel they have
influenced local priority setting.
26
Results
In your opinion have the funding and
implementation of local priorities been forgone
specifically in order to implement NICE guidance?
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Results
Section IV Categorisation of foregone
priorities
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Results

• DsPH were asked to detail up to two local
  priorities which were excluded from the final
  approved LDP
• 183 different services/technologies identified as
  foregone priorities
• Categorised for analysis into
• Service area
• Whether corresponding CHI indicator

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Results
Categorisation of foregone priorities into
service area
30
Results
Categorisation of foregone priorities CHI
Performance Indicators (for the 2003 Star Rating
exercise).
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Summary of Findings 1

• Large variety of arrangements methodology used.
  Little use of published economic analysis. Some
  PCTs felt prioritisation not feasible because of
  national must dos
• For majority of PCTs LDP is not discreet from
  identification of priorities
• Chief Executive Commissioning Managers are
  involved across the priority setting process
  DPHs are more involved in identification
  patient reps were involved in identification in
  approx half of PCTs only
• The local Acute/MH Trusts are most involved
  partners throughout process. LA are mainly
  involved in identification only
• National Political Influence, Media Coverage
  Public Opinion thought to be bigger influences on
  national priority than clinical need or cost
  effectiveness

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Summary of Findings 2

• Historical configuration of services and Internal
  Politics of local NHS organisations thought to be
  biggest local influences on priority setting,
  followed by clinical need and inequalities in
  access
• 76 of DPHs felt that National Work Programmes
  had displaced locally priorities either
  completely or to a large extent. 69 felt
  priorities specifically displaced because of NICE
• Waiting Lists were thought to have the greatest
  influence on local priority setting, followed by
  the NHS plan and NSF above NICE Guidelines and
  NICE TAs
• Foregone local priorities are across all service
  areas.
• Only 23 of foregone priorities had a clearly
  corresponding CHI performance indicator

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Since the study

• Study formed NICE submission to Wanless II and
  presented to DH and NICE board
• Recommendations of study for national guidance
  on clinical and cost effectiveness across a
  broader spectrum of technologies including public
  health initiatives hopefully will be addressed
  with the new NICE
• 2003-2006 Planning Framework move away from 62
  national targets to Core and Developmental
  Standards including public health
• Commissioning a patient lead NHS
• Realisation that PCTs too small to effectively
  commission/deliver services in some areas

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Remaining issues

• How can priority setting take further account of
  clinical and population need and less political
  and media influence?
• Will new arrangements of Super PCTs and larger
  StHAs be an opportunity to make priority setting
  more robust?
• How do we effectively engage public and partners
  in priority setting? our health, our care, our
  say fails to do this
• Will the economic crisis be a new opportunity to
  push priority setting up the agenda?
• Repeat of the survey in the new configuration?