Priority setting in practice; procedures, results, and participants’ opinions

Susanne WaldauPhD candidate Umeå University; Strategic prioritisation advisor, VCC

Västerbotten County Council, SwedenA politically managed, regional health care

organisation

Taxing & financing of health care

250 000 inhabitants

10 000 employees

1 university hospital + 2 district hospitals

~ 30 primary care units

Regional culture & development

BackgroundClearly exposed demands for funding of new technologies (~ 1,5% / year)

Expected economic strain

Identified need for a change of organisational behaviour (ie, ”Start respecting budget limits!”)

Long-term political interest in priority setting

Political instructions

”Create a process for priority setting” Desired features:

Secure openness in decisions & reasoningInclude the entire organisationCreate a forum for sharing of knowledge between politics, management and health careMake use of the medical professions’ expertisePolitical leadership takes on responsibility for reallocation decisions

Aim of the process

To fund new medical technologies by

disinvesting in low priority services;

ie,

Reallocation of given resources

to improve cost effectiveness

Common messages on motives, aims and procedures

A bright future – more patients can be helped;

All of health care cannot be publicly funded;

A robust economy necessary, allowing for development

Rationalization not sufficient. Prioritizing necessary, ie, setting limits to services;Priority setting to be based on principles of human dignity, needs/solidarity, cost effectiveness;

A long-term process. All involved. A common methodology. Reciprocal trust necessary.

.

A “Gold standard” analytical toolAdjusted version of The National Model for Transparent Vertical Prioritisation in Swedish Health Care (Carlsson et al 2007)

Aspect Specification / measure

Intervention Action or intervention

Health condition Condition and actual state

Severity level Very high; High; Moderate; Low

Patient benefit Very high; High; Moderate; Low

Cost effectiveness Good; Moderate; Doubtful; Don’t know

Evidence base Eg. SBU-report; National guidelines; Estimation

Rank 1-10; ”Don’t do”; R&D

Consequences For patients or other caregivers of limitation

A4R in the process

Publicity – openness in results Relevance – internal stakeholders included;

entire organisation participating; Gold standard methodology used for analysis

Revision – a learning process; each eventual political decision to be revisable

Enforcement – political will; long-term process

3 stages

1. Department level priority setting. Identify low priority 10 % of net budget. 2 months.

2. Intra-departmental priority setting.

10 groups/9 members/3 days. Quality revision. Identify low priority items = 4% of group net budget. A fortnight.

3. Political bargaining & decision making.

Reallocate 3%.

Ideal and reality in stage outputStage 1: Ideal 10 % - Reality 7.2%

Stage 2: Ideal 4 % - Reality 3.4 %

Stage 3: Ideal 3 % - Reality 2.2%

Stage 1: All depts. ( med. services) identified 10%

Stage 2: All depts. -1 participated

Stage 3: All depts. subject to budget reduction

8 most costly items/services to be limited (~ 30 MSEK)

Dept. InterventionR

an

k Net TSEK

Informatics Do not prolong certain Microsoft contracts 10 6 200

Primary care + Medicine

Cut use of test sticks for self-measurement of blood sugar at type 2 diabetes.

10 5 585

Primary care Abstain from free home delivery of pharmaceuticals by county council medical staff

D-D 4 500

Informatics Reduce computers by 5 % 10 4 500

Medicine Reduce hospitalisation jn acute wards for patients not severely ill for reasons like ”causa soc”, ”distress” or ”care taker ill”

10 3 303

Primary care Un-subsidised alternative for local oestrogene treatment first choice

9 2 000

Abstain from doctors visits 1 month after specific laryngitis infections

9 1 800

Reduce prescription of ”recipy-free” pharmaceuticals 9 1 661

New services fundedHabilitation for children & grown ups (4 MSEK)

Primary care (19 MSEK) COL, Prevention for children & young, Prevention of psychiatric illness and impairment, Palliative care, Coronary care

Psychiatry (24 MSEK)23 beds, Traumatized refugees, Addiction

Specialized hospital care (29 MSEK)Cancer pain treatment, Coronary care (NG), New pharmaceutics Screening abdomen aorta.

Diagnostics and medical services (12 MSEK)New lab methods, IT-security.

Staff/organization (25 MSEK)New competences, necessary staff and org. development

Main net results of prioritisation

Dis-investment

Investment MSEK% of net budget

Onchology -2,6 14,6 12 18,5Neurology & neuro surgery -0,1 6 5,9 16,9Coronary care -0,5 3,6 3,1 6,6Psychiatry -0,8 23,8 23 6,4Primary care -28,4 19,5 -8,9 -1,4Medicine/geriatrics -10,3 -10,3 -1,7Intensive care -8,1 0,4 -7,7 -2,3Informatics -13,2 8 -5,2 -3,9

DepartmentNet resultRe-allocation, MSEK

Results in relation to the ethical template

Better satisfaction of needs among severely ill and those with reduced autonomy – Principle of human dignity

Improvements for the severely ill by reducing services for the healthy or moderately ill – Principle of needs and solidarity

Improving outcome with given resources – Principle of cost effectiveness

1-yr implementation result

84% of disinvestments were implemented, = 74% of expected economic effects

Participants’ attitudes

Surveys to participants after Stage 1 (dept level priority setting);

Analysis on dept mgrs only; N=95, n=74 (78%)

Stage 2 (intra-dept priority setting); N=91, n=75 (82%)

Process complete; N=166, n=106 (64%)

Attitudes towards the outcome

9/10 thought the political decision was feasible and ethically acceptable, partly or on the whole.

Many were positively surprised over this, that the decision was taken, and unanimously.

New insights about own and other’s services –About the own during stage 1 About that of others during stage 2

Participants’ opinions

Identified improvement needs

Better preparationMore efforts on & time used for departmental priority settingImprove priority setting for service departments Better coordination between dept & intra-dept priority setting A new form for identification of services actual for new funding

Overall judgement

A strategy for re-allocation was created Priority setting was performed A political decision was made Economic space for development was createdResources were allocatedThe process was explicit, characterized by taking on responsibility and served as the intended learning process.

A successful process

Success factorsOrganizational wish for a strategy for re-allocation from low to high priority interventions

Goal-orientated process

Much effort on reflection before and during the process

Clear process leadership

A thorough communications strategy, integrated early in process and management

Political consensus about procedure and decision making and a strong political commitment during all of the process.

More results:

Waldau, Lindholm & Wiechel (2010). Priority setting in practice: Participants opinions on vertical and horizontal priority setting for reallocation. Health Policy.

http://dx.doi.org/10.1016/j.healthpol.2010.02.007

Very good

Rather good

SomeNone

No opinion

Future use of analysis methodology

12 26 50 7 5

Future use of analysis results

20 31 41 1 7

Future use of the dept level method and results, % of respondents

To a large extent

To a rather large extent

To some extent

None

No opinion

About own department (stage 1)

5 19 62 14 0

About other departments(stage 2)

27 48 25 0 0

New insights from priority setting, %

  Very positive

Rather positive

Rather negative

Very negative

No opinion

Horizontal priority setting in general

71 17 4 7 1

Own participation in horizontal priority setting

40 45 13 1 1

Relevance of group composition for discussions

15 59 16 3 7

Procedure as a whole 32 48 15 4 1

The procedure for intra-dept (horizontal) priority setting

Ethically acceptable

Well motivat

ed

Acceptable

Totally unethic

al

No opinion

Per cent 31 54 4 11

Decision feasibility

On the whole

Partly

Not very

Impossible

No opinion

Per cent 34 53 10 0 3

Ethical content & feasibility of political decision, %