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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, %