The potential value of priority-setting methods in public health investment decisions: qualitative findings from three English local authorities

This paper reports on an action-oriented research study providing decision support to three local authorities in England on the prioritisation of public health investment and disinvestment decisions. We adopted a political science perspective, using the multiple streams framework to investigate the use of prioritisation tools in public health spending decisions at a time of severe financial constraints. The challenges and implications of their potential use in everyday practice were explored. Twenty-nine interviews were conducted before the targeted decision support occurred and 19 interviews after the decision support had been delivered. Interviews were held with locally elected politicians, officers and public health professionals based within local government, NHS commissioners and the local independent consumer watchdog for health and social care. Targeted workshops with local stakeholders were facilitated in each site by health economist members of the project team. Structured observational notes were recorded during these workshops and integrated with the interview data. Many respondents expressed an interest in prioritisation tools although some scepticism was expressed about their value and impact on decision-making. This paper analyses the enablers and barriers to adopting priority-setting tools in a local government environment that by definition is political. The findings suggest that the adoption of priority-setting tools in decision-making processes in public health poses some significant challenges within local government and that certain enabling factors have to be present.     

Using economic evidence to support decision making: a case study of assertive community treatment within the UK National Service Framework for Mental Health

This study illustrates a process of accessing and utilising clinical and economic evidence in health care decision making. The scenario examined was that of a UK Health Authority evaluating evidence prior to the introduction of assertive community treatment (ACT), as part of guidance from the UK National Service Framework for Mental Health. The consistency between clinical and cost evidence from a number of sources (Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), HTA database, NHS Economic Evaluation database (NHS EED)) was also addressed, as was the usefulness of structured abstracts on NHS EED. The findings showed that within specified caveats ACT tends to be more effective and also less costly than alternative interventions; there is general agreement between sources principally reporting effectiveness and economic evaluations; and NHS EED abstracts are useful in the decision making process where information gaps exist. In terms of health care policy in the health authority examined, two ACT teams were subsequently introduced in the city of Leicester. Although systematic reviews and appraisals of evidence are arguably the gold standard in health care decision making, the study illustrates how the use of databases of structured abstracts can assist in making optimal choices in real life decision making scenarios.     

New labour and reform of the English NHS: user views and attitudes

Background The British National Health Service has undergone significant restructuring in recent years. In England this has taken a distinctive direction where the New Labour Government has embraced and intensified the influence of market principles towards its vision of a ‘modernized’ NHS. This has entailed the introduction of competition and incentives for providers of NHS care and the expansion of choice for patients. Objectives To explore how users of the NHS perceive and respond to the market reforms being implemented within the NHS. In addition, to examine the normative values held by NHS users in relation to welfare provision in the UK. Design and setting Qualitative interviews using a quota sample of 48 recent NHS users in South East England recruited from three local health economies. Results Some NHS users are exhibiting an ambivalent or anxious response to aspects of market reform such as patient choice, the use of targets and markets and the increasing presence of the private sector within the state healthcare sector. This has resulted in a sense that current reforms, are distracting or preventing NHS staff from delivering quality of care and fail to embody the relationships of care that are felt to sustain the NHS as a progressive public institution. Conclusion The best way of delivering such values for patients is perceived to involve empowering frontline staffs who are deemed to embody the same values as service users, thus problematizing the current assumptions of reform frameworks that market‐style incentives will necessarily gain public consent and support.     

Management education for undergraduate doctors. A survey of medical schools

Explores the extent to, and ways in which, doctors are prepared for their future role in management through the undergraduate medical curriculum. Surveys the colleges across the UK offering undergraduate medical education using both prospectuses and questionnaires to establish both inclusion of healthcare management/policy in curricula and the subject content offered. Establishes that the majority of colleges offer some teaching of health care management/policy although the areas of study included vary considerably. The emphasis in most institutions appears to be on introducing the structure and organization of the NHS together with decision making in respect of resource allocation often located within a public health programme. This leads to the tentative conclusion that the management education needs of future public health physicians are reasonably well served while those of hospital doctors and general practitioners need further investigation.     

A perspective on the analysis of credible commitment and myopia in health sector decision making

This paper examines the role of credible commitment in facilitating long-term decision making in health care. Commitments are defined as an undertaking by one party to perform a certain task in the future.Policy objectives and political imperatives within public sector organisations can often mean that decision making takes place on shifting institutional terrain. This creates incentives on decision making that favours those choices that yield short-term gains. Such myopia is not necessarily consistent with organisational objectives and the implementation of policies that promote such objectives. These incentive problems can be formally modelled in terms of prisoners' dilemma and co-ordination games. Measures that promote public sector organisations to credibly commit to various values or policy positions can assist in reconciling individual and organisational objectives by allowing decision makers, in good faith, to build long-term outcomes into their decision making. In effect they allow co-operation and co-ordination. Given these potential gains, credible commitment can occur spontaneously but when not, may need to be facilitated by a third party (notably the State). Such forms of commitment are usually apparent in various policy measures such as health service constitutions, long-term contracting, legislation and incentive payments.Measures that secure credible commitment allow the discount rate to be reduced on long-term decisions of not only public sector organisations but also those stakeholders who rely on stable public sector institutions. However, the importance of the notion of commitment needs to be recognised against the background of other institutional factors that may influence decision making.     

Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada

Approaches to involving the public in local health care decision making processes (and analyses of these approaches) have tended to treat participation and publics uniformly in search of the ideal method of involving the public or providing the same opportunities for public participation regardless of differing socio-economic, cultural, insitutional or political contexts within which decisions are made. Less attention has been given to the potential for various contextual factors to influence both the methods employed and the outcomes of such community decision-making processes. The paper explores the role that context (three sets of contextual influences more specifically) plays in shaping community decision-making processes. Results from case studies of public participation in local health-care decision making in four geographic communities in Ontario are presented. During the study period, two of these communities were actively involved in health services restructuring processes while one had recently completed its process and the fourth had not yet engaged in one. Several themes emerge from the case studies regarding the identification and role of contextual influences in differentially shaping participation in local health care decision-making. These include the propensity for communities with different social and structural attributes to engage in different "styles" of participation; the importance attached to "community values" in shaping both the qualitative and quantitative aspects of participation: the role of health councils, local government and inter-organizational collaboration as participation "enablers"; and the politicization of participation that occurs around contentious issues such as hospital closures.     

Modernisation, the NHS Plan and healthy communities.

This paper reviews the NHS Plan from the perspective of the Government's wider programme of "modernising" public services. Although broadly focussed, particularly highlights older people. Two dimensions of modernisation are identified. The NHS Plan is seen to be patient-cited--rather than citizen-centred. Argues further, that, if the economic, social and environmental causes of ill health are to be addressed more generally and if citizens are to be enabled to live in healthy, sustainable communities, planning for health services should logically be subordinate to planning for health. Health improvement plans should, therefore, be integrated within the wider community strategies for which local authorities are to have lead responsibility. Similarly, as ill health is recognised to be an important aspect of poverty, inequality and social exclusion, there is a strong case for the integration of the regional offices of the NHSE within the wider structure of regional governance. Finally, the personal social services should ensure that the values of social work and social care are not displaced by medical and nursing models which, historically, have shown little understanding of community development processes.     

Methods for public health economic evaluation: A Delphi survey of decision makers in English and Welsh local government

Standard reference case methods recommended for health technology appraisals do not translate well to a public health setting. This paper reports on a Delphi survey designed to elicit views of public health decision makers in England and Wales, about different methodological elements of economic evaluation. This is important as methods should align with the objective function of decision makers. The Delphi survey comprised two rounds, with round 1 allowing open‐ended recommendations in addition to 5‐point Likert scale responses. The final survey comprised 36 questions, and levels and strength of agreement were assessed using median values and mean absolute deviation of the median. The Delphi panel (n = 66) achieved high levels of agreement for costs, health, well‐being, and productivity impact to be important elements within an economic evaluation. The panel agreed that evaluations should be relevant to the local context and include costs and consequences over a lifetime horizon. There was a call for the transparent reporting of costs and effects for different population subgroups, and for different sectors. Overall, the panel revealed a preference for a flexible approach, understanding that economic evidence fits within a dynamic process of decision making. These results provide empirical evidence to inform guidelines for public health economic evaluation.     

How are policy makers using evidence? Models of research utilisation and local NHS policy making

STUDY OBJECTIVE: This paper is based on a qualitative study that aimed to identify factors that facilitate or impede evidence-based policy making at a local level in the UK National Health Service (NHS). It considers how models of research utilisation drawn from the social sciences map onto empirical evidence from this study. DESIGN: A literature review and case studies of social research projects that were initiated by NHS health authority managers or GP fundholders in one region of the NHS. In depth interviews and document analysis were used. SETTING: One NHS region in England. PARTICIPANTS: Policy makers, GPs and researchers working on each of the social research projects selected as case studies. MAIN RESULTS: The direct influence of research evidence on decision making was tempered by factors such as financial constraints, shifting timescales and decision makers' own experiential knowledge. Research was more likely to impact on policy in indirect ways, including shaping policy debate and mediating dialogue between service providers and users. CONCLUSIONS: The study highlights the role of sustained dialogue between researchers and the users of research in improving the utilisation of research-based evidence in the policy process.     

"It's a feel. That's what a lot of our evidence would consist of ": public health practitioners' perspectives on evidence

This article describes how evidence is defined and used in two British Columbia public health departments during the implementation of a Healthy Living initiative in 2009. Through interviews with 21 public health staff and decision makers, the author sought to investigate how "evidence" was defined by both frontline and management staff and how it was used in decision making. The authors found public health staff, particularly frontline practitioners, to be drawn to grassroots and local "lived experience" evidence. This tacit wisdom, in combination with evidence from academia and clinical evidence accessed through disciplinary or professional networks, offered a knowledge transition opportunity to inform decision making, rather than what can be characterized in the literature as unidirectional knowledge translation. It is often difficult for staff to digest and interpret research as part of their work day because of the volume and density of information that typically counts as evidence. Moreover, there exist challenges to identify and gather indicators as evidence of their work.     

Adoption of new health products in low and middle income settings: how product development partnerships can support country decision making

When a new health product becomes available, countries have a choice to adopt the product into their national health systems or to pursue an alternate strategy to address the public health problem. Here, we describe the role for product development partnerships (PDPs) in supporting this decision-making process. PDPs are focused on developing new products to respond to health problems prevalent in low and middle income settings. The impact of these products within public sector health systems can only be realized after a country policy process. PDPs may be the organizations most familiar with the evidence which assists decision making, and this generally translates into involvement in international policy development, but PDPs have limited reach into endemic countries. In a few individual countries, there may be more extensive involvement in tracking adoption activities and generating local evidence. This local PDP involvement begins with geographical prioritization based on disease burden, relationships established during clinical trials, PDP in-country resources, and other factors. Strategies adopted by PDPs to establish a presence in endemic countries vary from the opening of country offices to engagement of part-time consultants or with long-term or ad hoc committees. Once a PDP commits to support country decision making, the approaches vary, but include country consultations, regional meetings, formation of regional, product-specific committees, support of in-country advocates, development of decision-making frameworks, provision of technical assistance to aid therapeutic or diagnostic guideline revision, and conduct of stakeholder and Phase 4 studies. To reach large numbers of countries, the formation of partnerships, particularly with WHO, are essential. At this early stage, impact data are limited. But available evidence suggests PDPs can and do play an important catalytic role in their support of country decision making in a number of target countries.     

Investigating the social value of health changes

This survey has demonstrated that the Danish public is concerned with distributional aspects of health gains. They have a strong inclination to give priority to those in a more severe health state provided their expected benefits are large enough to bring them to the health level where their rival patients are without treatment. Results also indicated that the equity argument may not apply with equal force on all health dimensions. Respondents did to some extent trade-off equity for greater health gains. A nouvelle finding is that the valuations of health increments per se seem to be affected by whether questions are framed as individual or social choices. If social decision making is the issue, health gains which involve relieving patients of extreme problems are valued more highly than relief of minor ailments. These discrepancies between individual and social valuations suggest that the use of QALY values elicited from an individual's perspective may not be valid in social decision making.     

Managerialism and public attitudes towards UK NHS managers

Presents the results of empirical work examining public attitudes towards UK NHS managers. The findings indicate a strong lack of sympathy for managers. Discusses possible explanations for these results. The preferred explanation is that NHS managers as a group tend to share an ideology about the nature of the NHS and the role of management within the NHS which is at odds with the beliefs held by most members of the public on these matters. Explores the origins and nature of managerial ideology (managerialism) in the NHS and discusses possible reasons why the ideology might tend to be unpopular with the public. Concludes by suggesting that the traditional core values of the NHS as perceived by the public could be being violated by managerialism. This violation may be the principal cause for the low public esteem in which NHS managers are currently held.     

Exploring ethical terrain in public health.

Public health is rife with ethical challenges. Ethical principles and values are intrinsic to public health decision making, although they are generally not identified explicitly. One purpose of this article is to discuss public health goals as an ethical/value concern with attention to values that do and should underlie health care in the United States. A second purpose is to introduce frameworks for public health decision making that incorporate ethical considerations into community and health promotion perspectives of public health decision makers. Public health policy makers and providers are urged to explore ethical/value dimensions of the health care system and to use the ethical frameworks in their decision making, expanding the more individualistic perspective of traditional bioethics.     

Primary Care Groups and NHS Rationing: Implications of the Child B Case

Implementing The new NHS and the 1997 NHS (Primary Care) Act will gradually extend cash-limiting into primary health care, especially general practice. UK policy-makers have avoided providing clear, unambivalent direction about how to 'ration' NHS resources. The 'Child B' case became an epitome of public debate about NHS rationing. Among many other decision-making processes which occurred, Cambridge and Huntingdon Health Authority applied an ethical code to this rationing decision. Using new data this paper analyses the rationing criteria NHS managers and clinicians used at local level in the Child B case; and the organisational structures which confronted them with such decisions. Primary Care Groups are likely to confront similar rationing decisions in respect of 'gate-kept' NHS services. However, such rationing processes are not so easily transposed to open-access services such as general practice. NHS rationing decisions, especially in PCGs, will require a much more specific ethical code than hitherto used. This revised version was published online in July 2006 with corrections to the Cover Date.     

Clinical governance for public health professionals

This paper examines the issues specific to clinical governance for public health professionals. It highlights three levels at which public health is capable of promoting clinical governance: within the specialty of public health, across other National Health Service (NHS) organizations and as part of the public health responsibilities of health authorities. Current work is reviewed, and its focus on hospital and community NHS Trusts is noted. Current thinking on the introduction of clinical governance into clinical practice is interpreted to provide a framework for its development in public health professional practice.     

Deliberations about deliberative methods: issues in the design and evaluation of public participation processes

A common thread weaving through the current public participation debate is the need for new approaches that emphasize two-way interaction between decision makers and the public as well as deliberation among participants. Increasingly complex decision making processes require a more informed citizenry that has weighed the evidence on the issue, discussed and debated potential decision options and arrived at a mutually agreed upon decision or at least one by which all parties can abide. We explore the recent fascination with deliberative methods for public involvement first by examining their origins within democratic theory, and then by focusing on the experiences with deliberative methods within the health sector. In doing so, we answer the following questions "What are deliberative methods and why have they become so popular? What are their potential contributions to the health sector?" We use this critical review of the literature as the basis for developing general principles that can be used to guide the design and evaluation of public involvement processes for the health-care sector in particular.     

Deciding how NHS money is spent: a survey of general public and medical views

Objectives To examine the validity of the Prioritization Scoring Index (PSI) methodology by obtaining the views of our local population and clinicians regarding the criteria and weightings that should be used in deciding how NHS money is spent. Background We have used a PSI in Argyll and Clyde to allocate new money since 1996 and to determine priorities for our 1999/2000–2003/2004 Health Improvement Programme (HIP). Since the criteria and weightings for this methodology were developed subjectively, we sought to validate these by consulting local people and to change our methodology to take account of wider population views. Methods A postal questionnaire was sent to 1969 members of the general public, all 314 general practitioners and all 189 hospital consultants in Argyll and Clyde in March 1999. A reminder was sent after 4 weeks. Questions were asked about general funding and prioritization in the NHS and about specific issues relating to potential criteria for prioritization, including those used in our PSI methodology. Responses were analysed quantitatively in the Statistical Package for the Social Sciences (SPSS) and qualitatively through examination of the responses to open questions. Results The response rate was 51% for the general public and 71% for GPs and consultants. Respondents from the general public were broadly representative of the Argyll and Clyde population. The main findings were that: greater importance should be given to care that improves health, quality of life or prevents ill health rather than to cost, or to government and local health board priorities; half of the general public and most clinicians thought there should be a limit on NHS funding; extra money for the NHS should come from the national lottery (general public) or higher taxes on cigarettes and alcohol (clinicians); doctors should have the greatest influence in deciding how NHS money is spent; a higher priority should not be given to the health‐care needs of younger people rather than older people. Our public and clinicians would allocate approximately 50% of the prioritization weighting to direct patient benefits, 25% to the cost of health‐care and 25% to strategic health issues. Conclusions Consideration of public and clinician views suggests that a revised PSI should place greater weight on benefits to patients and lower weight on the cost of health‐care.     

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.     

Epistemology, evidence and experience: evidence based health care in the work of Accident Alliances

Evidence based health care has attracted considerable interest from NHS commissioners, public health specialists and sociologists as both a rational approach to decision making and as representing an ideological shift in health care. This paper explores the social construction of 'evidence' in one arena, that of the work of Accident Alliances. Interviews with key participants and observations of meetings suggest a high level of consensus that evidence was important for their work in terms of strategic decision making, operational planning and evaluation. However, evidence was framed differently across the professions and organisations involved in the alliances. Rather than being a neutral tool used to inform decision making, evidence was both constructed through professional practice and contributed to the construction of professional identity. The formal advocacy of evidence based interventions makes explicit a number of potential conflicts in inter-agency working, and Accident Alliances provide an illuminating case study of how these are managed in day-to-day working in health care.