Iestyn Williams

Rationing in health care: The theory and practice of priority setting

Foreword by Chris Ham Introduction The ethics of priority setting Public participation in priority setting Priority setting and economic evaluation Multi criteria decision analysis and priority setting processes The politics of priority setting Leadership in priority setting Disinvestment as a priority setting case study Conclusions and key lessons.

Organizational readiness for innovation in health care: some lessons from the recent literature

There is no single intervention that will trigger or ensure innovation in health care, as the interaction between the innovation and the context of its introduction is necessarily complex and variable. Although academic attention has recently turned to the role of organizations in promoting and embedding innovation, this literature remains light on prescription, and tends to ignore the issue of substitution and disengagement. Innovation needs to be adapted as well as adopted into organizational contexts and receptive climates for innovation can only be developed incrementally over time. This paper identifies recommendations for increasing the readiness of health-care organizations for innovation. Key organizational strategies for embedding innovation include: development of incentives; sophisticated knowledge management; interfunctional and interorganizational coordination and collaboration; and development of an innovation infrastructure. More attention is required to substitution and disengagement of interventions and practices (exnovation) in the current economic climate.

Implementing world class commissioning competencies.

Background The world class commissioning (WCC) programme was introduced in the English NHS in 2007 to develop primary care trust (PCT) commissioning of health services. There has been limited evaluation of health commissioning initiatives over the years and in particular little is known about how commissioners interpret and implement initiatives and guidance intended to strengthen commissioning. This research explores the development and implementation of WCC and draws implications for future commissioning arrangements. Methods This research draws on interviews with key informants (n = 6) and a literature review to analyse the aims of, and stimulus for, WCC. In-depth interviews (n = 38) were conducted in three PCTs in the north of England in 2009 to analyse the interpretation and implementation of WCC. Results The aims and rationale of WCC, in particular, the specification of commissioning skills and the aspirations to improve health outcomes, were largely welcomed and supported by interviewees. However, the implementation of WCC posed a number of challenges, including: availability of resources and knowledge; lack of a supportive organizational culture and networks; and the dominance of central government control. Conclusions The findings have implications for emerging clinical commissioning groups (CCGs) in the English NHS. Specifically, the research highlights the need for a system-wide approach to improving commissioning, including appropriately aligned policy and objectives underpinned by a co-ordinated and supportive organizational culture.

A politics of priority setting: Ideas, interests and institutions in healthcare resource allocation

Across a range of health care systems there is a responsibility placed on meso-level budget holders to set priorities and allocate resources within constrained budgets. The literature suggests that these organizations have typically defaulted to historical and/or political processes for decision making. Whilst the literature on resource allocation in health care attests to the political nature of decision making, this has remained largely under-theorized and therefore priority setters may be unfamiliar with the analytic benefits of applying insights from the broader political sciences. Conversely, policy scientists may know relatively little about existing research on how healthcare organizations make allocative and redistributive decisions. This paper aims to open a dialogue between these solitudes by exploring political effects on health care priority setting, using the interpretive concepts ideas, interests and institutions.

Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.

Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services

BackgroundThe need to better understand processes of removing, reducing, or replacing healthcare services that are no longer deemed essential or effective is common across publicly funded healthcare systems. This paper explores expert international opinion regarding, first, the factors and processes that shape the successful implementation of decommissioning decisions and, second, consensus as to current best practice.MethodsA three round Delphi study of 30 international experts was undertaken. In round one, participants identified factors that shape the outcome of decommissioning processes; responses were analysed using conventional content analysis. In round two, responses to 88 Likert scale statements derived from round one were analysed using measures of the degree of consensus. In round three the statements that achieved low consensus were then repeated but presented alongside the overall results from round two. The responses were re-analysed to observe whether the degree of consensus had changed. Any open comments provided during the Delphi study were analysed thematically.ResultsParticipants strongly agreed that three considerations should ideally inform decommissioning decisions: quality and patient safety, clinical effectiveness and cost-effectiveness. Although there was less consensus as to which considerations informed such decisions in practice, those that drew the most agreement were: cost/budgetary pressures, government intervention and capital costs/condition. Important factors in shaping decommissioning were: strength of executive leadership, strength of clinical leadership, quality of communications, demonstrable benefits and clarity of rationale/case for change. Amongst the 19 best practice recommendations high consensus was achieved for: establishing a strong leadership team, engaging clinical leaders from an early stage, and establishing a clear rationale for change.ConclusionsThere was a stark contrast between what experts thought should determine decommissioning decisions and what does so in practice; a contrast mirrored in the distinction the participants drew between the technical and political aspects of decommissioning processes. The best practice recommendations which we grouped into three categories—change management and implementation; evidence and information; and relationships and political dimensions—can be seen as contemporary responses or strategies to manage the tensions that emerged between the rhetoric and reality of implementing decommissioning decisions.

Disinvestment in health— the challenges facing general practitioner (GP) commissioners

The economic downturn is placing increasing pressure on the financing of health care. For many health care providers, this means difficult decisions need to be made over what will and will not be funded. The NHS has not typically been good at decommissioning and disinvesting in services. The recent proposed changes to the commissioning function will mean that clinicians will have a leading role in population-based priority-setting. This could well enhance the quest for legitimacy in relation to difficult resource allocation decisions. However, it is unlikely that GPs alone will be able to meet the challenges ahead, and reasonable disinvestment decisions will require GPs to engage with a number of stakeholders including government, interest groups and the wider civic society.

Making ‘what works’ work: The use of knowledge in UK health and social care decision-making

Abstract Decision-makers in UK health and social care are routinely asked to draw on evidence of ‘what works’ when designing services and changing practice. However, this paper argues that too much focus to date has been placed on a narrow definition of what constitutes valid ‘evidence’ (and one that privileges particular approaches and voices over others) and a simplistic conception of the decision-making function. As a result, policy and practice have too often been dominated by medical and quantitative ways of knowing the world, with such research approaches assumed to be more valid than other forms of enquiry. In contrast, the paper calls for a more inclusive notion of ‘knowledge-based practice’, which draws on different types of research, the tacit knowledge of front-line practitioners and the lived experience of people using services. This, the paper argues, will lead to a more nuanced approach to ‘the evidence’ and – ultimately – to better and more integrated decisions. Against this background, the paper outlines a suggested research agenda for those seeking to develop decision-making within these areas.

Resource scarcity and priority-setting: from management to leadership in the rationing of health care?

While continued interest in the application of priority-setting technologies is perhaps unsurprising in a time of austerity, they require sensitive implementation for their full potential benefits to be realized. This article looks at the role and value of leadership in addressing problems of a lack of perceived legitimacy and governance that have been raised in connection with the rationing enterprise. The potential and limitations of key leadership concepts such as ‘sense-making’ and ‘framing’ are explored, and notions of relational leadership and the importance of leading with political astuteness are discussed.

Offender health and social care: a review of the evidence on inter-agency collaboration

The involvement of health and social care agencies in crime reduction partnerships remains key to government strategy despite a growing awareness of the equivocal outcomes of inter-agency working in other settings. This paper reports findings from a literature review designed to assess the extent to which existing crime reduction partnerships have been able to overcome the barriers to joint working. The review focuses in particular on Drug (and Alcohol) Action Teams (D(A)ATs), Crime and Disorder Reduction Partnerships (CDRPs), Multi-Agency Public Protection-Arrangements (MAPPAs) and Youth Offending Teams (YOTs). A comprehensive review of published and unpublished literature suggests that these bodies have experienced similar difficulties to those highlighted in the broader partnership literature. The review further suggests that differences in ethical and professional outlook may be the most critical of these barriers as well as being the least explicitly addressed by recent government interventions. More work is required to build a consensus regarding the ethical underpinnings and fundamental objectives of partnerships across the care-control divide.