Priority setting in healthcare: thinking the unthinkable
I am just settling into my seat on Quantas flight Q9 in preparation for the 24-hour flight back to England. I have been in Melbourne, Australia, for 3 days at the International Society on Priorities in Healthcare 2014 conference entitled ‘Examining the past and contemplating the future – 20 years of priority setting’.
Sustainability of the NHS at risk
The scene for the conference was firmly set when I perused the complimentary Financial Times at Heathrow on the way out. ‘NHS crisis mounts as hospital deficits more than double’. The National Audit Office reported that a quarter of all Trusts – 63 in total – were in deficit by the end of this financial year compared with 25 in the previous year. The amount spent by the Department of Health on bailing out Trusts in financial distress had doubled, rising from £263m in 2012–13 to £511m in 2013–14. The gross deficit of NHS Trusts rose by 150% from £297m in 2012–13 to £743m in 2013–14. Margaret Hodge MP, Chair of the Public Accounts Committee, called the report ‘deeply alarming’. ‘I do not believe that it is an exaggeration to say that the future sustainability of our NHS is at risk,’ she added.
At the same time, the growing general election fever means that all parties are wary of giving any negative messages on what seems to be emerging as a key election issue, and so they ignore the fundamental challenge facing the NHS. A little more money is not the answer.
In his 5-year strategy, the new CEO of the NHS, Simon Stevens, has identified that even with efficiency savings (the like of which the NHS has never achieved in its 60-year history), more money will be needed to maintain the current level of service. He comments that bold new ways of working, driven by local initiatives and agreements rather than top-down directives, will have to be developed. He realises that the ‘easy’ efficiencies have already been implemented; the more painful ones are yet to come. Of course, real service efficiencies have been scarce; the bulk of the cost containment has come from freezing professional salaries for 5 years, which is effective as they represent 60% of the NHS annual budget. You may say that we have seen NHS financial crises come and go and the money always seems to be found. This time it is more difficult as the NHS has already been protected from the most savage of the austerity cuts – the continuing size of the national debt means that there is no other money.
Role of Clinical Commissioning Groups
So, who will be on the front line of instigating these new ways of working? With about 60% of the £110 billion annual budget of the NHS under their control, Clinical Commissioning Groups (CCGs) are going to be expected to find solutions. In 2013, 212 of these new organisations were established. Their role is to define the health needs of their local population and prioritise and commission appropriate services. They will identify which services should be expanded and which should be reduced. What criteria and information should CCGs take into consideration when making these difficult prioritisation decisions? And how might the patients and the public for whom health services are commissioned assess how their local CCG is performing?
Like other areas of healthcare, commissioning in the NHS has been influenced by the idea that decisions should be based on current knowledge of what works. In other words, decisions should be evidence-based. However, scientific evidence on clinical and cost-effectiveness, even when it is available, is not enough to make prioritisation decisions that are perceived as legitimate by those likely to lose out. In part, this arises from the fact that decisions on clinical and cost-effectiveness presuppose value judgements.
For example, the National Institute for Health and Care Excellence (NICE), working at a national level, derives its quality-adjusted life year values from a sample of the whole population rather than an affected patient group, on the grounds that the service is intended for the whole population. Whatever the merits of this position, it incorporates a set of value judgements that have implications for the assessment of cost-effectiveness. However, it is no longer even a case of the NHS offering funding for all cost-effective interventions (as proposed originally by Archie Cochrane) – hard choices are still going to have to be made that attempt to be fair and equitable within fixed finite budgets.
In recent years it has sometimes been argued that, given the controversial character of social values such as justice or equality, the most that can be expected from public institutions is the discharge of a procedural obligation to be accountable for whatever values that public institution uses. This, in turn, requires the idea that the values are reasonable, in the sense that a reasonable person could hold them, even if not every reasonable person does hold them. This approach is encapsulated by Harvard professor of population ethics Norman Daniels as ‘accountability for reasonableness’. However, even from this perspective, CCGs in England still need to justify their decision-making publicly by reference to content social values, as well as procedural ones.
Social values audit tool
That is why my collaborators and I have come to the conference. Following initial international collaborative research, we have created a social values audit tool that can be applied internally by, and externally to, decision-making organisations such as CCGs. That is to say that CCGs can apply the tool to evaluate where they stand when it comes to being explicit about the social values that feature in their decision-making processes, and the public can use it to assess the CCG’s work based on information that is available on public domains such as CCG websites.
At a time when calls for improved transparency are increasing, the tool provides a means to assess the status quo. Once the status quo is known, measures can be taken to adjust and improve local decision-making processes according to local needs. We have piloted the social values audit tool on a sample of CCGs in order to test whether it is a) useable by non-experts and b) yields results that would provide a basis for eliciting ‘value profiles’ of CCGs.
The draft audit tool can be viewed and downloaded at www.ucl.ac.uk/socialvalues. It consists of eight values. Within each value there are a series of prompts and a question that can be answered. In the UK, the Health Select Committee and the BMA were interested in our approach so we were keen to see what an expert international audience thought of our work, hence the trip to Australia.
The Melbourne conference
First, though, what did I learn from the conference? Well, not surprisingly, every country is facing the same challenges, although the magnitude of that challenge varies considerably. There was not much to learn from the USA, whose healthcare system is so inefficient that they would increase average life expectancy by 6 years if their system achieved just comparable value for money of the average OECD country.
For me, the most interesting solutions were put forward by New Zealand. They have already understood that clinical leadership is required to implement real changes. This is emerging slowly in the UK, with the managerial model introduced so many years ago by Sainsbury’s Roy Griffiths appearing to be on the wane. A keynote speech was provided by Anne Kolbe, Chair of the National Health Committee of New Zealand. It was salutary when a paediatric surgeon and previous president of their college was obviously at home with bioethical concepts of ‘accountability of reasonableness’ and health economic concepts of programme budgeting and opportunity costs.
Other speakers from New Zealand included Steffan Crausaz, CEO of PHARMAC, who showed what an integrated system working harmoniously together (rather than in competition) can achieve – a flat drug bill for the past few years to start with. Well, ‘it is a small country’ is the usual response and of course that is a factor. But there is no reason why a CCG working with a local health community cannot adopt this type of approach. The combination of openness of process and collective decision-making will be key for the success of achieving a fair and effective service in a fiscally tight and challenging environment. Talking about size – we heard that there are as many people in the metropolitan area of Mumbai in India as in the whole of Australia – now that really is a healthcare challenge!
The real value of these conferences, however, is not in the set talks, but sharing experiences with the other delegates. This can occur in the coffee breaks and also in the evenings at informal suppers. One night, taking the tram up the hill from the centre to the Fitzroy region near the university, the atmosphere was relaxed and the Greek food exquisite – the Australian sense of humour came through in the names of the local beer and wine.
Defining the benefits package
As we prepare for takeoff, I peruse the seating arrangement. I am in economy class; in front is ‘economy plus’ and in front of that is business and then first class. We are all going to the same place but in various degrees of comfort. You are acutely aware of this as you enter from the front of the plane and move slowly backwards through the ‘social classes’. However, we all get to Australia and back again: some pay £1000 and others £10 000. Are there any lessons here for the NHS?
We are constantly being told that the NHS should model itself on the aeronautical industry in terms of improving its safety record: checklists and learning from near misses and their no-blame culture. I have, however, always had a slight problem with this as the pilot does appear to have a personal stake in the plane landing safely. However conscientious doctors are in treating their patients, it is not quite the same as being in the same boat or, in this case, plane. But what about the ‘comfort’ side? I am not saying that we go the way of the budget airlines and you get a seat for the basic price and nothing else. Those in economy class had everything those in first class had – just less of it. Is it time to suggest that to continue to have a comprehensive NHS free at point of entry, we really should clearly define what is in the benefits package and what is outside it? You could get everything deemed as being cost-effective free (say, as assessed by NICE), but pay for extra interventions of dubious ‘value’ (might this be a better option than the ‘attendance fee’ that is being proposed for GP attendances by some?).
A final thought on the take-home message from the conference – for me it was that, in the future, all doctors increasingly will have a responsibility not only for their individual patients but also for the population of patients. As famous Chief Medical Officer, Sir George Godber, once said: ‘your responsibility is for the patient in the waiting room as well as the one in the consulting room’. He understood ‘opportunity costs’. And what about our presentation? It is early days, but there was definite interest.
Professor of Public Health, King’s College London