Transcript Commissioning in a Cold Climate

Commissioning in a Cold Climate
Can Prioritisation Really Help?
An English Perspective
Dr Henrietta Ewart,
Consultant in Public Health Medicine,
Solutions for Public Health, Oxford, UK.
What is priority setting?
• In any system where potential demand
exceeds available resource, choices are
inevitable
• This should include a process of deciding the
relative priority of different claims (eg for
different treatments or for different patient
groups) for scarce resources
• Some claims will always have to be rejected as
unaffordable
Legal Framework
• National Health Services Act, 2006 (England)
• Secretary of State’s duty to promote health service
• The Secretary of State must continue the promotion in
England of a comprehensive health service designed to
secure improvement—
 in the physical and mental health of the people of England, and
 in the prevention, diagnosis and treatment of illness.
 The Secretary of State must for that purpose provide or secure
the provision of services in accordance with this Act.
 The services so provided must be free of charge except in so far
as the making and recovery of charges is expressly provided for
by or under any enactment, whenever passed.
Legal Framework (2)
• In England, Primary Care Trusts (PCTs) have
delegated responsibility from the SoS for most
health care commissioning/funding.
• There are currently 152 PCTs organised within
10 Strategic Health Authority areas
• Under the NHS Act, 2006, PCTs have a
statutory responsibility not to exceed their
allocated budget
Economic Background
• Fixed funding inevitably means some things
will become unaffordable at some point, but
• The past 10 years have been ‘fat’:
– Average annual growth since 2000: 7%
– Average annual growth in NHS funding from 1948:
3%
– Average NHS inflation rate: 4%
Economic Future
• Need for efficiency savings of £15-20 billion
between 2011-2014 already identified
• Has been interpreted as a ‘flat cash’ situation
but even this would require considerable
changes in approach given background NHS
inflation rate (drivers: new technologies, aging
population)
Economic Future (2)
• Three models for protecting NHS funding
(Kings Fund and Institute for Fiscal Studies)
– Tepid - NHS receives annual increases of 2% from
2011-14
– Cold – NHS receives zero real terms change until
2014
– Arctic – NHS receives annual reductions of 2%
until 2014
Current Approach to Prioritisation
• Considerable variation between (and within)
PCTs
• Some have no formal policy/process
• Others have policy and process either within
their PCT or sharing resources across a
number of PCTs (eg across an SHA)
Existing processes - strengths
• Review of evidence for clinical and cost
effectiveness is core to the assessment
• More PCTs are developing explicit ‘ethical
frameworks’ to support decision making
• Decisions often involve multiple stakeholders
• Recent national work to spread good practice
(National Prescribing Centre, etc)
Existing Processes - Weaknesses
• Focus on marginal technologies (especially
new interventions)
• Lack of internal process to ensure that all
options for investment/disinvestment across
all programmes and budgets are included in
the process (not just new technologies and/or
expensive therapies identified through
individual requests)
Existing Processes – Weaknesses (2)
• Problems with culture change: some groups
(individuals) dislike process because –
– It feels very mechanistic
– Seems to exclude qualitative issues such as
patients’ views
– ‘It makes us take decisions that don’t feel right’
– It cuts across and weakens traditional power
bases
Existing Processes – Weaknesses (3)
• Quality of evidence review can be very varied, often due to
lack of resource (only had time for a quick Google search)
• Product is often a policy statement about a single point
intervention
• This means that the question of affordability is not taken
into account (a key issue with NICE TAGs)
• It is not clear how decisions taken through ‘priorities
methodology’ are weighed against other possible
investments/disinvestments that do not fit this evaluative
framework (eg pathway redesign)
• Not always clear how ‘priorities decisions’ fit in the overall
commissioning cycles (operating plan)
Result
• Currently, prioritisation is often structured as
‘single issue decision making at the margins’,
so it is not really ‘prioritisation’ at all
• Many decisions which commit PCT resources
are still being taken without a formal
evaluation and (real) prioritisation
• Therefore, different criteria are being applied
for different areas of activity – not good for
consistency/transparency or budget control
The Future
• We will still need to evaluate new
technologies but we will also need to:
• Reduce variations in clinical practice
• Disinvest from care that has poor evidence
base and/or is not value for money
• Do things differently – transformational
change, new models of care, service redesign
Priorities methodology can help with this
Prioritisation and Disinvestment
• Priorities processes traditionally focus on
interventions rather than processes or models
of care
• Uses established theory and practice of
evidence-based medicine (hierarchy of
evidence etc)
• Traditionally seeks to identify ‘low priority’
procedures which would not be routinely
funded
Prioritisation and Disinvestment (2)
• Traditional prioritisation can help with disinvestment. Many
areas for disinvestment have already been identified (eg
aesthetic procedures, D&C in women under 40, varicose
veins without skin changes, circumcision in the absence of
scarring balinitis, etc) – but implementing these is patchy
• EBM-based methodology can also be applied to ‘threshold
based’ (rather than ‘yes/no’) commissioning decisions (eg
indications for joint replacement, hysterectomy, back
surgery, cholecystectomy etc etc).
• More work could be done across whole pathways and/or
programmes – allowing identification of higher value vs
lower value interventions for given conditions (link with
programme budgeting)
Enhancing Prioritisation to Support
Disinvestment
• Greater use of EBM methodology to identify
sub-groups and thresholds
• Development of new methodology to enable
more consideration of ‘process’
issues/questions.
• Process questions do not fit with EBM
methodology – need something more
qualitative and iterative – eg ‘plan, do, study,
act’ (action research methodology)
Enhancing Policy Implementation to
Achieve Disinvestment
• Many ‘prioritisation processes’ end with the
production of a ‘policy statement’ (often
couched in ‘low priority’ terms)
• Little attention paid to implementation,
monitoring, evaluation and audit
• Even where an intervention has been judged
‘low priority’ audit shows that it may still be
going on
Culture Change
• PCTs need to embed prioritisation throughout
all commissioning/decommissioning
workstreams – including QIPP, practice based
commissioning, care programmes
• All stakeholders need to understand need for
prioritisation to underpin best use of
resources
• Need to encourage PICO thinking across all
areas of work
Conclusions
• Prioritisation can be (and is) used to decline
investment in new interventions, to withdraw
funding from existing ones and set thresholds
to improve practice and reduce variations
• Good prioritisation makes these decisions
against an explicit values framework which
has been developed with a wide range of
stakeholders. This is compliant with the
requirements of the NHS Constitution.
Conclusions (2)
• Developing prioritisation to support the
identification of and disinvestment from lower
value health care will require a greater focus on:
• thresholds and patient groups
• Developing methodology to evaluate and
prioritise processes (pathways, service delivery
models) as well as interventions
• Ensuring that all commissioning decisions are
taken against the same evaluative framework.
• Ensuring adequate resource to do the work
(potential to share across PCTs)
Thankyou...
Dr Henrietta Ewart
Consultant in Public Health Medicine
[email protected]