Prioritisation and Resource
Allocation
Dr. Arun Ahluwalia
Dr. Carol Chatt
In the next 5 years the NHS will have to set out
more clearly what is – and what is not –
available to patients free at the point of use on
the NHS. Do you….
•
•
•
•
•
Strongly agree
Tend to agree
Tend to disagree
Strongly disagree
Don’t know ?
Prioritisation
• We saw earlier that when demand exceeds
available resources, choices have to be made.
• Choices implies priorities
What is rationing?
• The allocation of resources, services or goods
under some rational, emotional or political
criterion
• Is this the same as prioritisation or resource
allocation?
Implicit and Explicit Rationing
• Implicit rationing: care is limited, but neither
the decisions, nor the bases for those decisions
are clearly expressed.
• Explicit rationing: care is limited and the
decisions are clear, as is the reasoning behind
those decisions.
Rationing in the UK
“Rationing in Great Britain has been implicit…It
is a silent conspiracy between a dense,
obscurating bureaucracy, intentionally avoiding
written policy for macroallocation (rationing),
and a publicly unaccountable medical
profession privately managing microallocation
so as to conceal life and death decisions from
patients”
(Crawshaw, 1990)
Explicit methods of rationing
1. League tables
2. Programme Budgeting and Marginal Analysis
(PBMA)
1. League Tables
• Economic evaluations produce information on
cost-effectiveness
• If using comparable outcomes (e.g. QALY) can
‘rank’ according to cost-effectiveness
• Can use resultant ‘league table’ to allocate
resources to most cost-effective first
• E.g. The Oregon Plan
The Oregon Plan
• In 1989, the state of Oregon embarked on a controversial
experiment in the financing of health care. The state planned
to add many uninsured people to the Medicaid program and
to pay for this expansion by reducing the Medicaid benefit
package — more people would be covered, but for fewer
services.
• In 1991, Oregon ranked more than 700 diagnoses and
treatments in order of importance. The state legislature then
drew a line at item 587; treatments below the line would not
be covered. Oregon had openly embraced the “R word”:
rationing
• On February 1, 1994, the Oregon Health Plan, with its
prioritized list, went into operation
•
Thomas Bodenheimer The Oregon Health Plan — Lessons for the Nation N Engl J Med 1997;
337:651-656
• In 1987, Coby Howard contracted acute lymphocytic
leukemia and needed a bone marrow transplant.
Earlier that year, the Oregon legislature had
discontinued Medicaid coverage for organ
transplantation
Problems with League Tables
• Limited data on cost-effectiveness
• Studies to determine cost-effectiveness use
different methods
– e.g. compare new treatment to placebo / current
treatment
• Determining cut-off point
• Needs constant updating
2. PBMA
• combines both technical and political
rationing methods
• Principles:
– If £1 were to be made available that £1 should be
invested in an area in which the most benefit
would be gained
– If £1 were to be disinvested that £1 should be
taken away from an area where the least benefit
would be lost.
Which programme would you invest in?
Which programme would you disinvest in?
100
90
80
Marginal benefit for next unit
of resources
70
Benefits
60
Current benefit
50
40
Marginal loss for removing unit
of funding
30
20
10
0
A
B
C
Programmes
D
E
Steps of PBMA
1. Choose a set of meaningful programmes.
2. Identify current activity and expenditure in those
programmes.
3. Think of improvements.
4. Weigh up incremental costs and incremental benefits and
prioritise a list.
5. Consult widely.
6. Decide on changes.
7. Effect the changes.
8. Evaluate progress.
Brambleby and Fordham, 2003. What is PBMA? Oxford University
PBMA
• Main objective of PBMA is to reallocate
resources so that benefits are maximised
• Successful implementation of PBMA requires
resources to be shifted from the
disinvestment list to the investment list
• But,
– Disinvestment is difficult
– PBMA is data hungry and time consuming
– Difficult to obtain a representative advisory panel
Methods of rationing
• In your area of work, how do you deal with
high demand?
Methods of rationing
• Delay
– Create waiting lists
• Denial
– Non-urgent or unsuitable cases are not done
Possible methods for quantity
rationing
• In groups of 4 choose your preferred 3
methods of quantity rationing and your least
favourite 3 methods.
• (10 minutes)
In Summary,
• Prioritisation is inevitable in a resource limited
health care system
• PBMA is attractive to decision-makers
– Seems ‘rational’
– Supported by DoH
• However, it is not easy
– Increasing the input of various stakeholders may
shift the culture of the public / media to accept
rationing