Commissioning in a Cold Climate

1. Commissioning in a Cold Climate Can Prioritisation Really Help? An English Perspective Dr Henrietta Ewart, Consultant in Public Health Medicine, Solutions for Public Health, Oxford, UK.

2. What is priority setting? • In any system where potential demand exceeds available resource, choices are inevitable • This should include a process of deciding the relative priority of different claims (eg for different treatments or for different patient groups) for scarce resources • Some claims will always have to be rejected as unaffordable

3. Legal Framework • National Health Services Act, 2006 (England) • Secretary of State’s duty to promote health service • The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement— • in the physical and mental health of the people of England, and • in the prevention, diagnosis and treatment of illness. • The Secretary of State must for that purpose provide or secure the provision of services in accordance with this Act. • The services so provided must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

4. Legal Framework (2) • In England, Primary Care Trusts (PCTs) have delegated responsibility from the SoS for most health care commissioning/funding. • There are currently 152 PCTs organised within 10 Strategic Health Authority areas • Under the NHS Act, 2006, PCTs have a statutory responsibility not to exceed their allocated budget

5. Economic Background • Fixed funding inevitably means some things will become unaffordable at some point, but • The past 10 years have been ‘fat’: • Average annual growth since 2000: 7% • Average annual growth in NHS funding from 1948: 3% • Average NHS inflation rate: 4%

6. Economic Future • Need for efficiency savings of £15-20 billion between 2011-2014 already identified • Has been interpreted as a ‘flat cash’ situation but even this would require considerable changes in approach given background NHS inflation rate (drivers: new technologies, aging population)

7. Economic Future (2) • Three models for protecting NHS funding (Kings Fund and Institute for Fiscal Studies) • Tepid - NHS receives annual increases of 2% from 2011-14 • Cold – NHS receives zero real terms change until 2014 • Arctic – NHS receives annual reductions of 2% until 2014

8. Current Approach to Prioritisation • Considerable variation between (and within) PCTs • Some have no formal policy/process • Others have policy and process either within their PCT or sharing resources across a number of PCTs (eg across an SHA)

9. Existing processes - strengths • Review of evidence for clinical and cost effectiveness is core to the assessment • More PCTs are developing explicit ‘ethical frameworks’ to support decision making • Decisions often involve multiple stakeholders • Recent national work to spread good practice (National Prescribing Centre, etc)

10. Existing Processes - Weaknesses • Focus on marginal technologies (especially new interventions) • Lack of internal process to ensure that all options for investment/disinvestment across all programmes and budgets are included in the process (not just new technologies and/or expensive therapies identified through individual requests)

11. Existing Processes – Weaknesses (2) • Problems with culture change: some groups (individuals) dislike process because – • It feels very mechanistic • Seems to exclude qualitative issues such as patients’ views • ‘It makes us take decisions that don’t feel right’ • It cuts across and weakens traditional power bases

12. Existing Processes – Weaknesses (3) • Quality of evidence review can be very varied, often due to lack of resource (only had time for a quick Google search) • Product is oftena policy statement about a single point intervention • This means that the question of affordability is not taken into account (a key issue with NICE TAGs) • It is not clear how decisions taken through ‘priorities methodology’ are weighed against other possible investments/disinvestments that do not fit this evaluative framework (eg pathway redesign) • Not always clear how ‘priorities decisions’ fit in the overall commissioning cycles (operating plan)

13. Result • Currently, prioritisation is often structured as ‘single issue decision making at the margins’, so it is not really ‘prioritisation’ at all • Many decisions which commit PCT resources are still being taken without a formal evaluation and (real) prioritisation • Therefore, different criteria are being applied for different areas of activity – not good for consistency/transparency or budget control

14. The Future • We will still need to evaluate new technologies but we will also need to: • Reduce variations in clinical practice • Disinvest from care that has poor evidence base and/or is not value for money • Do things differently – transformational change, new models of care, service redesign Priorities methodology can help with this

15. Prioritisation and Disinvestment • Priorities processes traditionally focus on interventions rather than processes or models of care • Uses established theory and practice of evidence-based medicine (hierarchy of evidence etc) • Traditionally seeks to identify ‘low priority’ procedures which would not be routinely funded

16. Prioritisation and Disinvestment (2) • Traditional prioritisation can help with disinvestment. Many areas for disinvestment have already been identified (eg aesthetic procedures, D&C in women under 40, varicose veins without skin changes, circumcision in the absence of scarring balinitis, etc) – but implementing these is patchy • EBM-based methodology can also be applied to ‘threshold based’ (rather than ‘yes/no’) commissioning decisions (eg indications for joint replacement, hysterectomy, back surgery, cholecystectomy etc etc). • More work could be done across whole pathways and/or programmes – allowing identification of higher value vs lower value interventions for given conditions (link with programme budgeting)

17. Enhancing Prioritisation to Support Disinvestment • Greater use of EBM methodology to identify sub-groups and thresholds • Development of new methodology to enable more consideration of ‘process’ issues/questions. • Process questions do not fit with EBM methodology – need something more qualitative and iterative – eg ‘plan, do, study, act’ (action research methodology)

18. Enhancing Policy Implementation to Achieve Disinvestment • Many ‘prioritisation processes’ end with the production of a ‘policy statement’ (often couched in ‘low priority’ terms) • Little attention paid to implementation, monitoring, evaluation and audit • Even where an intervention has been judged ‘low priority’ audit shows that it may still be going on

19. Culture Change • PCTs need to embed prioritisation throughout all commissioning/decommissioning workstreams – including QIPP, practice based commissioning, care programmes • All stakeholders need to understand need for prioritisation to underpin best use of resources • Need to encourage PICO thinking across all areas of work

20. Conclusions • Prioritisation can be (and is) used to decline investment in new interventions, to withdraw funding from existing ones and set thresholds to improve practice and reduce variations • Good prioritisation makes these decisions against an explicit values framework which has been developed with a wide range of stakeholders. This is compliant with the requirements of the NHS Constitution.

21. Conclusions (2) • Developing prioritisation to support the identification of and disinvestment from lower value health care will require a greater focus on: • thresholds and patient groups • Developing methodology to evaluate and prioritise processes (pathways, service delivery models) as well as interventions • Ensuring that all commissioning decisions are taken against the same evaluative framework. • Ensuring adequate resource to do the work (potential to share across PCTs)

22. Thankyou...Dr Henrietta EwartConsultant in Public Health MedicineHenrietta.ewart@ntlworld.com