Priority-setting and rationing in healthcare: Evidence from the English experience

In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching ‘correct’ resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped.     

Economic assessment of nutritional recommendations

The effect of consumers’ compliance with nutritional recommendations is uncertain because of potentially complex substitutions. To lift this uncertainty, we adapt a model of consumer behaviour under rationing to the case of linear nutritional constraints. Dietary adjustments are derived from information on consumer preferences, consumption levels, and nutritional contents of foods. A calibration exercise simulates, for different income groups, how the French diet would respond to various nutrition recommendations, and those behavioural adjustments are translated into health outcomes through the DIETRON epidemiological model. This allows for the ex-ante comparison of the efficiency, equity and health effects of ten nutritional recommendations. Although most recommendations impose significant taste costs on consumers, they are highly cost-effective, with the recommendations targeting salt, saturated fat, and fruits and vegetables (F&V) ranking highest in terms of efficiency. Most recommendations are also economically progressive, with the exception of that targeting F&V.     

Rationing through risk assessment in clinical genetics: all categories have wheels

This paper focuses on issues relating to rationing in the context of cancer genetics. It indicates how the allocation of scarce resources to patients in need is not simply a managerial process, but something that is routinely woven into the fine web of organisational activity. In the framework of this study – executed within a UK regional cancer genetics clinic – much of that activity circulates around issues relating to risk assessment. The author first illustrates how risk assessments in cancer genetics affect the distribution of clinical benefits in general. Following that, it is explained how professionals assemble risk categories and how the assembly work relates to rationing. The paper concludes by suggesting that rationing principles should more properly be seen as stratagems that are called upon and manipulated by lay and professional parties, rather than as a set of guide rules imposed top‐down by managerial agents.     

The cost of rationing medical care by insurance coverage and by waiting

This paper raises the question of the least-cost institutional mechanism to secure the value of certainty by reducing risk over the purchase of medical care. Two methods of reducing risk are evaluated: financing medical care with ‘complete insurance’, that is, ready access to medical care that is free at the point of purchase; and rationing by waiting time in a national health service that supplies a limited volume of medical care. The first system corresponds to the type of insurance held by most people in the United States, while the latter represents a stylized model of a national health service. The cost of over-utilization of services by insured consumers in the U.S. is substantial - larger on a per-family basis, and far larger for the nation, than the cost of under-utilization by those who lack insurance. The cost of rationing by waiting is estimated to be between $541 and $828 per family (in 1984 dollars). Thus, both systems involve costly mis-allocation of resources.     

Impact of bed availability on requesting and offering in-hospital intensive care unit transfers: A survey study of generalists and intensivists

Purpose

To evaluate whether bed availability affects a physician's decision to request or offer an intensive care unit (ICU) transfer.

Materials and Methods

We administered mail-based surveys to determine the respondents’ probability of either requesting an ICU transfer (generalist respondents) or offering an ICU transfer (intensivist respondents). Respondents randomly received clinical vignettes that were identical except for the number of available ICU beds (one or seven available ICU beds). Respondents also made predictions about the patient's outcomes.

Results

Among generalists and intensivists, there were wide ranges in decisions about ICU transfer. In the Generalist ICU request study, the average probability of transfer with one versus seven available ICU beds was 52.2% and 58.5% (P = .41), respectively. In the Intensivist ICU offer study, the average probability of transfer with one versus seven available ICU beds was 62.5% and 57.4% (P = .24), respectively. The most consistent association with decisions about ICU transfer was the predicted probability that a patient would require an ICU bed in the future if not transferred currently.

Conclusions

There is high variability in the decision to request or offer ICU beds. There was not a significant association between bed availability and ICU transfer decisions.     

Deliberating Tarceva: A case study of how British NHS managers decide whether to purchase a high-cost drug in the shadow of NICE guidance

This paper examines audio-recorded data from meetings in which NHS managers decide whether to fund high-cost drugs for individual patients. It investigates the work of a Welsh individual patient commissioning (IPC) panel responsible for sanctioning the purchase of 'un-commissioned' treatments for exceptional cases. The case study presented highlights the changing rationales used for approving or denying a cancer drug, Tarceva, during a period when NICE first suggested it was not cost effective, but then changed its position in a final technology appraisal recommending use when the cost did not exceed that of an alternative product. Our data show how decisions taken in the shadow of NICE guidance remain complex and subject to local discretion. Guidance that takes time to prepare, is released in stages, and relates to particular disease stages, must be interpreted in the context of particular cases. The case-based IPC panel discourse stands in tension with the standardised population-based recommendations in guidance. Panel members, who based their decisions on the central notions of 'efficacy' and 'exceptionality', often struggled to apply NICE information on cost-effectiveness to their deliberations on efficacy (clinical effectiveness). The case study suggests that the complex nature of decision making makes standardization of outcomes very difficult to achieve, so that local professional judgement is likely to remain central to health care rationing at this level.     

Fair Rationing is Essentially Local: An Argument for Postcode Prescribing

In this paper I argue that resource allocation in publicly funded medical systems cannot be done using a purely substantive theory of justice, but must also involve procedural justice. I argue further that procedural justice requires institutions and that these must be "local" in a specific sense which I define. The argument rests on the informational constraints on any non-market method for allocating scarce resources among competing claims of need. However, I resist the identification of this normative account of local justice with the actual approach to local decision-making taken within the UK National Health Service. I illustrate my argument with reference to the case of provision of In Vitro Fertilisation within the UK NHS.