Value for money priorities are achieved by getting a good understanding of local needs, says Stuart Shepherd.
NHS Isle of Wight has adopted a “socio-technical” approach to prioritising value for money investment decisions.
The process directly involves health professionals, patients and community stakeholders and supports world class commissioning.
The primary care trust has worked with the London School of Economics on a Health Foundation funded project that allows for comparison of a range of interventions while responding to strategic commissioning goals.
The process began with a number of facilitated stakeholder workshops across previously identified priority areas that reflected the island’s biggest health and life expectancy challenges - cancer, circulatory diseases, respiratory diseases, mental health and children’s services.
This was where lead commissioners, clinicians, patients and others anticipated gaps in provision and generated ideas for service improvement. The ideas were expressed in terms of their impact on health and the “average” patient who would benefit. A consensus was reached as to the most beneficial.
As a follow-up, the lead commissioners then completed a template that gave a specific operational description of each intervention, with detail such as numbers of new staff, numbers of people to benefit, their social demographics, the severity of their condition at point of access and quantitative or qualitative input on the health benefits.
Twenty-one potential strategic initiatives were taken forward to a more formal priority-setting event attended by directors, commissioning managers, representatives from the local authority, patient groups and the trust’s professional executive committee. This was organised as a decision conference and facilitated by Mara Airoldi, a researcher from LSE.
“The templates allow us to be sure that as we go on to compare what is a set of very different initiatives ranging from lifesaving acute treatments to public health interventions they are all framed within a common set of references,” says Ms Airoldi.
“Visual aids are introduced which help to demonstrate each initiative’s overall health benefit,” she continues. “On one axis these show the estimated number of people to benefit - determined by a mix of statistical data and judgement - with the average benefit per person on the other axis.”
In each of the priority areas, the initiative determined as having the most benefit per person was assigned a reference score of 100, with other initiatives scored relatively. Whereas other processes might use quality-adjusted life year calculations or randomised control trials to assess comparative levels of health gain, the participants at the Isle of Wight event were facilitated in the use of behavioural decision theory to consider and determine relative benefits for each initiative.
“We often don’t have QALYs or trial results, so I used techniques to help them visualise the average person to benefit from each intervention,” says Ms Airoldi. “They thought of them in terms of age, gender, socio-economic status, severity of disease and so on. If, for instance, three cancer interventions had been put forward, they were able to imagine each one being invested in and then which ‘average’ patient would go on to benefit the most. All of the lengthy discussions that produced the final decisions were informed by peer review.”
Case Study, NHS Isle of Wight
NHS Isle of Wight has been using the priority setting initiative since 2007. It has helped the PCT make investment decisions about better patient education for inhaler use that has seen emergency admissions for asthma halved. As a result of the approach, it also provides more community dementia support and takes a proactive approach to healthy living with schools and parents.
A further comparison of benefit scores between different priority areas was reached by multi-criteria decision analysis. This considered health benefit, the potential to reduce health inequalities, the probability of success when factors such as change management and workforce issues are taken into account, and extra funding.
With the average benefits per person for every intervention transferred to a common scale and represented visually, event participants were able to make value for money comparisons with adjustments for impact on health inequalities. Again, these were represented visually and took in to account not just value for money but also the number of people set to benefit, both important attributes.
- Get patients involved in priority setting - they bring expertise
- Let the visuals do the talking - the graphic representation of low-level population interventions juxtaposed with acute interventions for a handful of people give a real sense of scale and scope
- Look closely at how socio-economic groups can benefit and opportunities for reducing health inequalities where interventions suggest lots of potential for wide population level improvement
- Money to fund interventions is not the only resource implication - low-cost initiatives that offer good population health improvements or inequality reduction need strong managers to implement them
“What decision conferencing and multi-criteria decision analysis allow us to do is take account of the fact that decisions are never based on completely rational or logical information,” says Jenifer Smith, public health director and chief medical adviser, NHS Isle of Wight. “It allows the social interaction and value judgements to be made explicit.”
“Getting the opinion of the patient as expert into the process has not been difficult,” Dr Smith continues. “They really value the chance to contribute and keep coming back.”