Public opinion and rationing in the United Kingdom

In the United Kingdom and as in all other countries, health care professionals ration access to diagnosis and treatment. Throughout its history there has been a reluctance to acknowledge the existence, let alone the nature of rationing processes and public opinion about them. Several health policy reforms are discussed with reference to their approach to dealing with the scarcity of health care resources. Data taken form the 1998 Eurobarometer Survey are analysed to examine public opinion regarding rationing issues, such as funding for health care, the need to set limits in health coverage, the role of stakeholders in setting priorities, and the use of age, and other factors, as a criteria for setting priorities.     

Priority setting in Austria

Priority setting and rationing are not yet matters of public debate in Austria. Before a discussion on rationing is undertaken, the incentive system concerning the financing of health care services needs to be reformed, especially in relation to the reimbursement of hospitals and physicians. This is necessary if a waste of scarce resources is to be avoided. Although methods and principles of priority setting and rationing are not openly discussed, several rationing techniques are already performed as organisational tools. A Eurobarometer survey of the population regarding their satisfaction with the health care system confirms the presumption that Austrians are not aware of the fact that rationing methods already exist.     

Clarifying the scope of Italian NHS coverage. Is it feasible? Is it desirable?

The reduction in National Health Service (NHS) expenditure as a share of total health care expenditure, the fragmentation of the NHS into 21 regional systems and the implementation of a 'quasi-market' on the provider side of the system has pressed the government to define and specify, in detail, the set of services that are to be guaranteed by the public sector. To understand whether rationing can be more rational and explicit in the Italian NHS, the following are analysed: (i) the new positive list of drugs, as a major example of limiting and making more rational NHS pharmaceutical coverage; (ii) the Di Bella case, as an example of the difficulties of rational policy-making on sensitive issues; (iii) what Italian people think about health care rationing and priority setting (using the 1998 Eurobarometer Survey);( iv) the criteria defining the set of 'essential services' to be guaranteed to all Italian citizens, which are contained in the recently released National Health Plan. The 'revolution' that has taken place in the pharmaceutical sector shows it is feasible to limit, in an explicit and rational way, the extent of NHS coverage. However, the re-classification of the positive list should be regarded as an exceptional event in the history of Italian social policy. The 'Di Bella' case, on the contrary, shows that limiting NHS coverage can be very unpopular, and that the Italian cultural and social context can be unfavourable for the implementation of hard choices. Public attitude toward rationing seems to confirm that Italians are not familiar with rationing issues. Thus, it is very difficult to predict whether the national government will really go ahead with the implementation of a 'list of essential services' and whether this attempt will be successful. Rationing and priority setting should be discussed in the context of a general debate concerning the future of the Italian NHS.     

Rationing health care in France

Since the Plan Juppé (1995), many facets of the French health care system have been the target of new legislative measures. This paper discusses the main features of the financing and provision of health care services, and focuses on issues related to priority setting and rationing. For more than 20 years, successive but systematic changes have been implemented. Most changes and measures affected the demand and supply of health care services, as well as their prices. Attempts to control demand focused mainly on the increase of user charges (ambulatory care as well as the hospital sector). Control over the volume of supply consisted, for the most part, in limiting the number of health professionals and restricting hospital beds. As far as payment is concerned, the French public authorities had set a general system of administrative prices (negotiated fees for private practice physicians, pharmaceuticals and other medical goods) and implemented global budgets for public hospitals. Among the new features designed in 1996, which target both cost-containment and quality of care, we emphasise the Parliament's involvement in setting national expenditure targets for sickness funds, the experimentation with a gatekeeper-like system (médecin référent), the development of practice guidelines and quality controls through the accreditation of hospitals. As the 1998 Eurobarometer Survey clearly shows, none of these reforms is easy to implement; they will take time to be accepted and will need physicians' support to succeed.     

The use of nominal group technique in identifying community health priorities in Moshi rural district, northern Tanzania

This article highlights issues pertaining to identification of community health priorities in a resource poor setting. Community involvement is discussed by drawing experience of involving lay people in identifying priorities in health care through the use of Nominal Group Technique. The identified health problems are compared using four selected village communities of Moshi district in Kilimanjaro region, Tanzania. We conducted this study to trace the experience and knowledge of lay people as a supplement to using 'health experts' in priority setting using malaria as a tracer condition. The patients/caregivers, women's group representatives, youth leaders, religious leaders and community leaders/elders constituted the principal subjects. Emphasis was on providing qualitative data, which are of vital consideration in multi-disciplinary oriented studies, and not on quantitative information from larger samples. We found a high level of agreement across groups, that malaria remains the leading health problem in Moshi rural district in Tanzania both in the highland and lowland areas. Our findings also indicate that 'non-medical' issues including lack of water, hunger and poverty heralded priority in the list implying that priorities should not only be focused on diseases, but should also include health services and social cultural issues. Indeed, methods which are easily understood and applied thus able to give results close to those provided by the burden of disease approaches should be adopted. It is the provision of ownership of the derived health priorities to partners including the community that enhances research utilization of the end results. In addition to disease-based methods, the Nominal Group Technique is being proposed as an important research tool for involving the non-experts in priority setting in Tanzania.     

Governmentality and risk: setting priorities in the new NHS

The aim of this paper is to explore priority setting issues in the British National Health Service (NHS). It focuses on the changing way in which rationing issues are managed by a sample of English health authorities in the wake of Health Service reforms and the separation of function between purchasing and providing health care. The paper employs the conceptual framework of 'governmentality', associated with the French social theorist Michel Foucault, to analyse this aspect of contemporary British health policy. Governmentality analysis situates social and economic change as reflecting shifts in the 'mentality' of government. The consequence of this new articulation is that the concepts of priority setting and rationing become embedded as dominant discourses and emergent practices within health policy. Equally important is the way in which the perceived shift in the formula of governance also results in a different conceptualisation of the subject of health governance based on the management of individual risk.     

Health care rationing in an age of uncertainty: a conceptual model

Explicit health care rationing or priority-setting is the use of institutional procedures for the systematic allocation of resources within health care systems. With the establishment of priority setting systems in various countries in the past two decades, research has been conducted on their principles, methods and institutional aspects. This paper draws on the sociology of science and technology to propose an uncertainty-focused conceptual model of the relationship between knowledge practises and political processes in health care rationing. Taking a case-study approach, the paper explores the public controversy about whether dementia drugs should be available on the UK National Health Service. It shows how three aspects of the controversy - loose institutional framing, open membership and hybrid knowledge - worked together to enable the use of a 'pragmatic balance' between rules and cases. Placing this outcome within the space of possibilities suggested by the model, the paper suggests that accepting and fostering the exploration of uncertainty at the core of health care priority setting systems should provide those systems with increased social robustness.     

Doctors' professional values: results from a cohort study of United Kingdom medical graduates

OBJECTIVES: To examine young doctors' views on a number of professional issues including professional regulation, multidisciplinary teamwork, priority setting, clinical autonomy and private practice. METHOD: Postal survey of 545 doctors who graduated from United Kingdom medical schools in 1995. RESULTS: Questionnaires were returned by 95% of the cohort (515/545). On issues of professional regulation, teamwork and clinical autonomy, the majority of doctors held views consistent with current General Medical Council guidance. The majority supported the right of doctors working in the NHS to engage in private practice. Most respondents thought that public expectations of doctors, medicine and the NHS were too high, and that some form of rationing was inevitable. On many issues there was considerable variation in attitudes on the basis of sex and intended branch of medicine. CONCLUSIONS: The results highlight the heterogeneity of the profession and the influence of specialty and gender on professional values. Doctors' attitudes had also been shaped by broader social changes, especially debates surrounding regulation of the profession, rising public expectations and the need for rationing of NHS care.     

Ethische Grundlagen der Priorisierung im Gesundheitswesen

The debate about priorities in healthcare has also started in Germany. Because of the special moral significance of health and healthcare, priority setting in healthcare also involves ethical issues. After clarifying the relationship between priority setting and rationing, I first discuss whether it is ethically acceptable or even mandated to set priorities in healthcare. If this first question is answered with “yes”, the following question is how the priorities can be determined in an ethically defensible way. I will try to show that it is impossible to justify priorities in healthcare within a liberal theory of justice that is neutral towards substantive conceptions of the good life. We rather need a deliberative decision process about how we want to live in the face of illness, suffering, and death. Only by reference to a substantial concept of a good life is it possible to define and justify healthcare priorities. A national priority-setting commission could play an important role in stimulating this deliberation and developing general recommendations according to which criteria and procedures priorities should be set in the German healthcare system. The application of this general framework requires the cooperation of medical scientific and physician organizations.     

Priority setting, public opinion and health care system in Spain]

OBJECTIVES: To examine the determinants of attitudes towards some "general criteria" guiding the financing, provision and satisfaction of the Spanish health system. First we examine the degree of acceptance of a publicly funded health system such as the use of an intergenerational equity criteria for health care rationing based on patient's age. Second, employing the same sample we analyse the determinants of citizen's satisfaction with the health system in order to identify the profile that defines attitudes of Spanish population to their health system. METHODOLOGY: We undertake a quantitative analysis of the public opinion survey Eurobarometer 49.1 (1998) for a subsample of the Spanish population. The Eurobarometer is a periodical public opinion survey representative of European Union (EU) citizens. Due to the categorical nature of individual responses to public opinion surveys, the model estimated is an ordered probit. The explanatory variables used refer to socio-economic status and political attitudes. RESULTS: There appears to be a consensus on the criteria that public sector should go a way forward from what the public envisages as "essential health care". 73.5% of the populations rejects a libertarian criteria that sustains that individuals are self responsible for funding non-essential health care. This attitude is especially supported by male with leftists political tendencies and high education achievement. The use of age-related criteria to ration health care (fair innings) is rejected by a 81.5% of the population. However, we find that self interest is the main criteria guiding this attitude since elderly and middle and high income individuals tend reject the use of this criteria more than other groups. Satisfaction with the Spanish health system is higher than other southern EU countries, as Italy and Greece but still far from the levels achieved by Scandinavian and northern EU countries. Political attitudes, age and socio-economic status are positively associated with a higher satisfaction.Conclusions: Health systems reforms that significantly reduce the collective funding of health systems would not be accepted by the majority of the population. As it happens in other EU countries, attitudes on the financing and provision of health care are influenced by political attitudes. Health reforms reducing the extent of health care funding would be rejected by the population. The use of and age-related criteria for health care rationing would be envisaged as discriminatory against the elderly. Health system satisfaction is in an intermediate position and its sensitive to demographic and socio-economic composition of the Spanish population, still far from the levels achieved by Scandinavian and northern EU countries. This results show a particular general criteria when evaluating health systems key elements, and may be expected to vary when applied to the concrete decision making scenario. Finally, it should be noted that quantitative analysis of general surveys is subject to large limitations. Thus, caution should be posed when interpreting these results, always should be seen as complementary of other studies using alternative methodologies (those using qualitative and experimental methodologies).     

What do hospital decision-makers in Ontario,Canada, have to say about the fairness of priority setting in their institutions?

Background  

Priority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'.     

Health research priority setting in selected high income countries: a narrative review of methods used and recommendations for future practice

Research priority setting aims to gain consensus about areas where research effort will have wide benefits to society. While general principles for setting health research priorities have been suggested, there has been no critical review of the different approaches used. This review aims to: (i) examine methods, models and frameworks used to set health research priorities; (ii) identify barriers and facilitators to priority setting processes; and (iii) determine the outcomes of priority setting processes in relation to their objectives and impact on policy and practice.Medline, Cochrane, and PsycINFO databases were searched for relevant peer-reviewed studies published from 1990 to March 2012. A review of grey literature was also conducted. Priority setting exercises that aimed to develop population health and health services research priorities conducted in Australia, New Zealand, North America, Europe and the UK were included. Two authors extracted data from identified studies.Eleven diverse priority setting exercises across a range of health areas were identified. Strategies including calls for submission, stakeholder surveys, questionnaires, interviews, workshops, focus groups, roundtables, the Nominal Group and Delphi technique were used to generate research priorities. Nine priority setting exercises used a core steering or advisory group to oversee and supervise the priority setting process. None of the models conducted a systematic assessment of the outcomes of the priority setting processes, or assessed the impact of the generated priorities on policy or practice. A number of barriers and facilitators to undertaking research priority setting were identified.The methods used to undertake research priority setting should be selected based upon the context of the priority setting process and time and resource constraints. Ideally, priority setting should be overseen by a multi-disciplinary advisory group, involve a broad representation of stakeholders, utilise objective and clearly defined criteria for generating priorities, and be evaluated.     

Budget- and Priority-Setting Criteria at State Health Agencies in Times of Austerity: A Mixed-Methods Study

Objectives. We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity.Methods. We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate).Results. Respondents identified 5 key criteria: whether a program was viewed as “mission critical,” the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed.Conclusions. We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.The governmental public health enterprise continues to face myriad financial and other challenges, including eroding infrastructure, lack of political support, and increasing health problems associated with behavioral health. Since the 2008 economic downturn, thousands of public health jobs have been eliminated, growth has been stifled, and the public health workforce has continued to shrink because of attrition and retirement.1,2 During times of scarcity, the means of allocating resources is of particular interest and importance. However, the characterization and study of resource allocation decision-making is more common in health care compared with public health, where knowledge is limited, especially among national health care systems in developed nations.3–8 Globally, there is a growing interest in the systematic setting of priorities in health care and public health in developing countries, where funds are in shorter supply.4,9–18 A much greater proportion of total health dollars in the United States are spent on health care compared with public health, which is about 3% of total health spending by some estimates.19 This emphasis on spending for health care has created a dearth in research on setting of priorities and budgets in public health; we are not aware of any studies that have examined criteria use in public health priority setting at state health agencies (SHAs), although a few have examined priority setting in local health departments (LHDs). Two studies in particular indicated that the most important priority-setting criteria employed in LHDs were funding availability, mandates, being the sole provider, the size and scope of consequences, politics, and public interest or acceptability.20,21 In 2011, the Association of State and Territorial Health Officials (ASTHO) released their Profile of State Public Health, Volume 2, providing the first collection of revenue and expenditure data that allowed for meaningful comparisons of public health spending across SHAs. These were the first data available in recent years regarding actual spending by SHAs, but these data sets did not capture processes: how SHAs set budgets and why they give priority to the areas they do. We focused on 1 particular component of the priority-setting process—criteria use—because of the critical role criteria were found to play in setting budgets and priorities more broadly in the course of this study, and as reported elsewhere.22     

Priority dilemmas in psoriasis care and visions of a future care in a group of administrators, politicians and professionals in northern Sweden

During the 1990s priority discussions were actualized in Sweden due to increased demands on health care and limited resources. In the county of V?sterbotten in northern Sweden, with large rural areas, the decision makers faced special challenges due to distances and cost. Despite discussions striving for fairness in priorities, decision makers are still dealing with limited resources and difficult priority decisions regarding different diseases and treatments. In this study we aimed at describing views on priorities in public psoriasis care and visions of a future care among politicians, administrators and professionals in the county of V?sterbottten in northern Sweden. Qualitative research interviews were performed with 23 key-persons. The findings revealed priority dilemmas about issues on organization, accessibility and ethics. Visions of a future care appeared as ambitions of a more effective care with good accessibility, continued research, information and a holistic approach in priorities. We conclude that dilemmas revealed in this study were a reflection of a gap between intentions and practice. In efforts to reduce these dilemmas we suggest methods with fairness in economic planning and priority setting, with concrete, official statements about the dominating views on which the priorities are based, and public information about these statements.     

Are economic evaluations and health technology assessments increasingly demanded in times of rationing health services? The case of the Argentine financial crisis

OBJECTIVES: After 4 years of deepening recession, Argentina's economy plummeted after default in 2002. This crisis critically affected health expenditures and triggered acute rationing. Our objective was to explore health decision-makers' knowledge and attitudes about economic evaluations (EE) and whether health technology assessment (HTA) were increasingly used for decision making. METHODS: A qualitative design based on semistructured interviews and focus groups was used to explore how decision makers belonging to different health sectors implement resource allocation decisions. RESULTS: Informants were mostly unaware of EE. The most important criteria mentioned to adopt a treatment were evidence of effectiveness, social/stakeholder demand, or resource availability. Despite general positive attitudes about EE, knowledge was rather limited. Although cost considerations were widely accepted by purchasers and managers, clinicians argued about these issues as interfering with the doctor-patient relationship. Other important perceived barriers to HTA use were lack of confidence in the transferability of studies conducted in developed countries and institutional fragmentation of the Argentine healthcare system. The new macroeconomic context was cited as a justification of implicit rationing measures. Although explicit priority setting was implemented by many purchasers and managers, HTA was not used to improve technical and/or allocative efficiency. CONCLUSIONS: The crisis seems to be a strong incentive to extend the use of HTA in Argentina, provided decision makers are aware as well as involved in the generation of local studies.     

Physicians as violence prevention activists--a qualitative study

Few studies have examined the challenges facing physician activists: health care providers who engage in unpaid, non-clinical work to effect change in social issues pertaining to public health. We conducted focus groups with 19 health care providers active in violence prevention; data were analyzed using qualitative methods. Five themes emerged: (1) personal experience had generated participants' activism; (2) physicians believed they were uniquely qualified as violence prevention activists; (3) violence prevention inside the health care setting often overshadowed outside activism; (4) they feared being overwhelmed by demands of activism; and (5) they felt isolated and valued networking, especially locally, to relieve isolation. Findings illustrate the complex demands of violence prevention work on today's busy physicians.     

To accept,or not to accept,that is the question: citizen reactions to rationing

Background The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions. Objective To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service. Design Qualitative interviews, analysed by phenomenography, describing perceptions by different categories. Setting and participants Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care. Results Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one’s (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services. Conclusions This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to ‘opt out’ of the public sector solution if they consider rationing decisions unacceptable.     

Public involvement in health care priority setting: an economic perspective

Background  Public involvement in health care decision making and priority setting in the UK is being promoted by recent policy initiatives. In 1993, the British Medical Association called for public consultation where rationing of services was to be undertaken. The approach to priority setting advocated by many health economists is the maximization of quality adjusted life years (QALYs). Typically, for a particular health care programme, the QALY calculation takes account of four features: (1) the number of patients receiving the programme, (2) the survival gain, (3) the gain in quality of life and, (4) the probability of treatment success. Only one feature, that relating to quality of life, is based upon public preferences. If the QALY is to be used as a tool for health care resource allocation at a societal level then it should incorporate broader societal preferences.
Methods  This study used an interview-based survey of 91 members of the general public to explore whether the traditional QALY maximization model is a good predictor of public responses to health care priority setting choices.
Results and conclusions  Many respondents did not choose consistently in line with a QALY maximization objective and were most influenced by quality of life concerns. There was little support for health care programmes that provided a prognostic improvement but left patients in relatively poor states of health. The level of respondent engagement in the survey exercise was not sensitive to the provision of supporting clinical information.     

Priority setting in the provincial health services authority: survey of key decision makers

Background  

In recent years, decision makers in Canada and elsewhere have expressed a desire for more explicit, evidence-based approaches to priority setting. To achieve this aim within health care organizations, knowledge of both the organizational context and stakeholder attitudes towards priority setting are required. The current work adds to a limited yet growing body of international literature describing priority setting practices in health organizations.     

The public and professional interface with priority setting in the National Health Service

The agenda of purchasers of health care in the National Health Service (NHS) is increasingly dominated by the issue of priority setting. This is a consequence of the interplay of limited budgets, increasing demands on health care services and a contracting process that makes explicit resource decisions that were previously implicit through clinical discretion. Purchasers are increasingly concerned to show that their decisions are rationally informed and embody a professional and public consensus. This paper examines literature that suggests variables, other than rational determinants, play a part in the process of priority setting at the purchaser and provider level. The interface of public, political and professional agendas in this process help explain the lack of national uniformity in both setting priorities and their translation into practice. Consequently, there is a need for more comprehensive exploration of the relationship between the setting of priorities and their effect on practice.