Equality, Equity and Policy: Prioritisation Frameworks and Equity of Service Provision
As outlined in module 4c, section 2: priorities and rationing, approaches to priority setting vary internationally. Some areas such as Norway, the Netherlands, Sweden, and Denmark choose to outline the principles of priority setting for consideration when providing health services. Other areas define priority setting practice by establishing national bodies that recommend which services should be offered; the National Institute for Health and Care Excellence (NICE) in the UK and the Oregon Plan are examples of the latter approach. (Sabik & Lie, 2008)
These prioritisation frameworks developed in response to key issues facing population access to health care. Norway placed an emphasis on reducing waiting times for treatment, whilst the Oregon Plan aimed to reduce the rate of expensive interventions with little proven benefit and use the savings to increase the number of people covered by a health insurance plan. (Sabik & Lie, 2008) Prioritisation frameworks can be influenced by political pressures: for example when an expensive breast cancer medication was not provided in England and Wales, public outcry prompted a NICE review recommending that the medication should be made available. (Barrett et al, 2006)
At a local level, decision makers may use frameworks to ensure a systematic approach to health service prioritisation and the most efficient and fairest use of scarce resources.
Yorkshire and the Humber Public Health Observatory have outlined three frameworks which have been used to prioritise health services in the UK, these are summarised in the table below.
Table 1 Prioritisation frameworks identified by Yorkshire & Humber Public Health Observatory
|Programme Budgeting and Marginal Analysis (PBMA)||
Programme Budgeting is the evaluation of current resources, spend and allocation. Marginal Analysis is the assessment of benefits gained and costs incurred by investing in a service, or benefits lost and savings made by disinvesting in a service. See module 4d, section 5: techniques of economic appraisal for more detail on PBMA.
|Save to Invest||This framework was created in response to variation in the provision of certain non-essential surgical procedures. Each procedure has a standard set of ‘access criteria’, which if applied rigorously would result in a reduction in rates of the procedure. Minimum and maximum levels of service reduction are estimated, along with the associated cost savings.|
|Multi-Criteria Decision Analysis (MCDA)||
· identifying criteria with which to assess the benefits of an intervention
· applying weightings to each of the criteria
· scoring the intervention according to the benefit weightings
· using cost data to calculate cost/ benefit ratios for comparison with other interventions
In practice, frameworks are often adapted to meet the requirements of budget holders, and there is a wide spectrum of how formal and involved the prioritisation process is. On the one hand, a discussion or decision by those with budget-holding responsibility on how to invest/disinvest can constitute a prioritisation process, and often there is not the luxury to be able to follow a formal prioritisation process. For example, an under- or over-spend at year end will often need quick decisions about how to allocate resources or make cuts, and this will sometimes involve opting for decisions to be based on pragmatism rather than equity.
At the other end of the spectrum there are prescribed processes based on health economics principles. A useful case study is the process involving the London School of Economics and the Isle of Wight (Airoldi et al, 2014) which documents the process to allocating a fixed resource for an unspecified purpose. Healthcare commissioners submitted proposals for investments that were otherwise difficult to compare, and through an iterative process (led by facilitators) they identified the intervention which would achieve the 'best' health gain for the population.
Prioritisation frameworks can be useful when faced with service developments (availability of new treatments or diagnostic procedures, changes in policy or redesign of health care pathways) which demand reallocation of funding. (Austin, 2015a) NHS England’s Right Care programme recommends that the IDEAL framework (originally designed to evaluate surgical and interventional innovations) can be adapted and used when dealing with service developments and funding requests for treatments that are new and of unproven effectiveness. For more information on Individual Funding Requests in the UK see section 2: priorities and rationing. (Austin, 2015a,b)
Regardless of the tool that is used, any prioritisation decision making should be based on certain key principles: the process must be transparent and documented, benefits and disbenefits identified and assessed (including equity, equality, health gain, and cost), and necessary stakeholders engaged.
- Airoldi M et al (2014). STAR – People-Powered Prioritisation: A 21st-Century Solution to Allocation Headaches. Accessed online, see weblink below
- Austin D (2015a). Part 1 Using IDEAL when dealing with proposed service developments. Accessed through NHS England Right Care Resource Centre, see link below
- Austin D (2015b). Part 2 Using IDEAL when dealing with individual funding requests (IFRs). Accessed through NHS England Right Care Resource Centre (see link below)
- Barrett A, Roques T, Small M, Smith RD (2006). Rationing: How much will Herceptin really cost? BMJ, 333: 1118- 1120.
- Sabik L, Lie R (2008). “Priority Setting in health care: Lessons from the experiences of eight countries.” International Journal for Equity in Health, 7:4.
- Yorkshire & Humber Public Health Observatory (2010). Prioritisation frameworks and tools.
- NHS England Right Care Resources http://www.rightcare.nhs.uk/index.php/resourcecentre/
- STAR- People powered prioritisation
© Rachel Kwiatkowska 2016, Robert Tolfree 2016