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'Justifying health priorities will not be easy'

About 212 clinical commissioning groups will be formally established on 1 April 2013. They are expected to improve patient outcomes, reduce health inequalities and maximise the population’s health.

In today’s tight financial environment this is a tough call and prioritisation decisions are inevitable. The government’s aspiration for a locally led patient focused NHS will only be realised if each of these CCGs is able to justify its decisions to suspicious professionals, patients and the public.

How this will be achieved remains unclear. Indeed the Department of Health’s position is that it wants to encourage local solutions and minimise downward directives. Its influence will be through the commissioning outcomes framework (COF), but reaction from commissioner organisations to the publication of early COF indicators has suggested that even this level of control is not acceptable.

Michael Dixon of the NHS Alliance considers that: “clinical commissioning groups are going to be the new innovators so it is really important that we do not hem them in, having to fulfil lots of quality indicators when they might have other priorities”. This stance suggests that top-down directives may be resisted.

Of course, all this is not surprising. Across the world clinicians and policy makers face daily the challenge of making healthcare prioritisation decisions, balancing the objectives of securing high quality, comprehensive healthcare within limited resources. One way to deal with these challenges is to search for greater value for money through evidence-based assessment of interventions that work - the aim of the National Institute for Health and Clincial Excellence’s approach. Yet there is no reason to think all hard trade-offs and tragic choices can be overcome by greater efficiency in the use of resources. Priority setting that leads to the dilution, delay or denial of NHS coverage of some treatments or services will be a central feature of commissioning for years to come.

Priority setting involves technical analyses of clinical and cost effectiveness, but it also requires judgements of social value - the values expressed by society or communities. Such values include justice, solidarity and patient autonomy. Even clinical effectiveness presupposes social values in the assessment of the quality of life that an intervention will deliver.

Social values are also relevant to the policy processes by which priority setting decisions are reached, as procedural values like transparency, accountability and participation affect the perceived sense of legitimacy of decisions. CCGs will be accountable for decisions that need to reflect the views of their local communities.

Identifying and incorporating the views of the community you serve is difficult. Despite years of seeking to address this issue, NICE continues to be controversial. To understand how values held by communities influence prioritisation decisions, a new research and policy network has been established.

In February 2011, researchers and policy makers from 11 countries met in London to share experiences, and to explore how prioritisation decisions in healthcare are made and how they can be improved. The first thing to evolve from the deliberations was a framework for assessing the role of social values in priority setting. The aim of the framework was to detail the pattern of such values, which can be divided into two broad categories.

The first includes substantive values like clinical effectiveness, cost effectiveness, equity, solidarity and autonomy; the second includes process values of transparency, accountability and participation. The purpose of the framework is not to prescribe a set of values but to suggest a checklist for analysis, which can provide the basis of a “value profile” for CCGs. To support this approach the research programme has now established a case study website where examples of prioritisation decisions can be collected and discussed..

This is a new venture and we welcome CCGs to join the network. The overall aim of the programme is to convert the framework and case studies into a practical decision support tool for prioritisation. This is not intended to supplant the existing approaches but to complement them. It will enable CCGs and the patients they serve to gauge their underlying value profile as a precursor to applying other more detailed methods to enact those values.

Peter Littlejohns is professor of public health at King’s College London. Albert Weale is professor of political theory and public policy at University College London. Sarah Clark is Economic and Social Research Council Research Associate at University College London.

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