Priority-setting as governance in the UK National Health Service

1. Health Services Management Centre Priority-setting as governance in the UK National Health Service Freeman et al

2. Background • Professional Dominance model (‘clan governance’) of Friedson (1970) • Identify with peers rather than managers • Mobilize professional contacts when required • Dominated by elites (patronage) • Reduced professional dominance (Harrison 2004) • Rise of general management • Consultant revalidation / appraisal • CHI / HCC / CQC • Convergence of professional / managerial principles (Leicht & Fennell (2001) • ‘neo-entrepreneurial’ practices • Professional brought in on a ‘project’ basis • Team-based work • Captured by algorithm-driven approaches to diagnosis/treatment • Monitoring and sanctioning of performance

3. Alignment of clinician / manager narratives • EBM / EBP crossover in late 1990s • Increasing appraisal (e.g. ‘NICE’) • Use of National Service Frameworks and outcomes guidance Scope and scale - difficult to contest the legitimacy of the guidance

4. Governmentality “any more or less calculated and rational activity undertaken by a multiplicity of authorities and agencies, employing a variety of techniques and forms of knowledge that seek to shape conduct through working through our desires, aspirations interests and self-beliefs for definite but shifting ends and with a diverse set of relatively unpredictable consequences, effects and outcomes.” (Dean, 1999, p.11)

5. The formation of disciplinary institutions, practices and discourses; • In which legitimated forms of power • Seek the formation of obedient, self-regulatory subjects These forms depend on professional expertise; codifying the knowledge-base of professionals, which becomes an institutionalised and legitimated form of authority.

6. Clinical governance requires clinicians to set the standards of practice to which they are held accountable - through self-surveillance and upward reporting (Flynn, 2004) • Expertise is central, regulation requiring self-surveillance and accountability. • Regulation underpinned by discretion, entrepreneurship, flexibility and commitment (‘liberty’) - rather than ‘obedience to rules’

7. Governmentality “any more or less calculated and rational activity undertaken by a multiplicity of authorities and agencies, employing a variety of techniques and forms of knowledge that seek to shape conduct through working through our desires, aspirations interests and self-beliefs for definite but shifting ends and with a diverse set of relatively unpredictable consequences, effects and outcomes.” (Dean, 1999, p.11)

8. Health care policy: the World Class Commissioning (WCC) agenda • In health care PCTs have become the principal site of resource allocation decisions • Decisions take place across a number of areas: - • investment of new services • investment into core services • investment in service improvement activity • disinvestment of existing funds and services • Lots of different activity happening across England – development of a range of tools and approaches to aid the priority setting process

9. Health care policy: the World Class Commissioning (WCC) agenda • Increased competition, accountability and transparency • Implied rationality and EBA to decision making- RCTs, CEA and Programme Budgeting Analysis (PBMA), national guidance (NICE) • Disinvestment as well as investment to be considered • Focus on local- enables local service design, innovation and development • Engage with all stakeholders – including patients and the public • Planned approach to financial management sustainable future focused -monitor performance and withdraw if not meet

10. The local reaction: the case study site • The PCT executive and commissioning team identified that commissioning was driven by historical trends and arrangements • General perceptions that old system was inconsistent, lacked transparency • Involved only a small number of individuals in actual decision making • No systematic feedback mechanism • No appeals procedure • Central gov’t policy accelerated policy change

11. The new priority setting process • Follows the Accountability for Reasonableness framework (AFR) Daniels and Sabin, 1998- requirement to include deliberation and debate- as well as information and evidence- process considers a process of fair if it is able to demonstrate transparency, allows for revision. • Framework fits well with the WCC agenda

12. The new priority setting process: two stages • Stage 1: Set and identify priorities – develop bids against PCT strategy and involve key individuals- • Providers (bid authors) used Modified Tool(MT) to develop bids. • MT- 16 questions each having maximum score – with higher scores given to ‘quality evidence’ i.e. RCTs CEA etc

13. Stage 2: The panel process • Panel members pre-scored the bids using the tool • Panels comprised – Executives, Commissioners, Patient rep., Clinicians • Bid authors invited to attend sessions – 10 minutes for questions • Panel members score bids • Average score collated • Following all panels rank order developed

14. Current work of priority setting in this context • Limited work around validity of approaches focus tends to be on effectiveness of commissioning processes • Focused on aspects of the wider of commissioning rather than looking at priority setting in the commissioning context. • Limited understanding of both what priority setting tools and processes are being used within PCTs around the country and how these are being operationalised in practice and for what effect.

15. Methods: • Explore how these tools and approaches are enacted in context • Undertook observations of panel sessions, evaluation of documentary evidence and interviews with a number of stakeholders

16. Descriptive Results • 91 bids were scored across 4 panel sessions • 68 were actually scored • Top 22 bids funded • Number of members ranged from 11 (panel 4)- 16 (panel 3) • Breath of experience and skills was seen as a strength of panel • CEO- removed himself from process- rhetoric different than reality

17. A4R: Deliberative element • Rhetoric – used to sell the process • In panel – individuals undertook minimal deliberation • The discussion tended to focus on -micro level detail (Technique, Contractual) • Happened outside of panel- Clan culture (clinicians, managers, regions)

18. ‘yes I did speak to panel members outside of panel…..I only discussed with those who worked in the East’ (Bid author) • ‘I did discuss my scores with other panel members before the panel…we tended to have similar views on bids…I discussed with Bill (clinician)… I value his expertise’ (panel member clinician)

19. Response to the rational process • dissonance with the rational process of Priority setting tended to relate to lack of evidence • process flawed – not fit for purpose tended to go with ‘gut instinct’- own knowledge and expertise “tool not fit for purpose complex criteria that is not transferable to this setting…I just went with my ‘gut instinct’ used by own experience

20. Response to rational process • shift towards rational model welcomed change better – overcome lack of information by being consistent in approach to scoring “I think by being consistent you are being fair to all bids and it all gets sorted in ‘the wash’ that way…”

21. Tool and process • suggested that the tool got in the way of the process and the same outcome could be achieved without it “The process was costly and no better than a back of the envelope calculation which probably would come up with the same answer”( clinician)

22. Tool and process • The tool helped to structure the process makes the process more defensible. “…it aids the process, helps to structure it and we are all singing from the same hymn sheet if you get my meaning…helps when we are questioned about our decision, last year we could not say why things got funded and others didn’t this year we can…(Manager)

23. What does this tell us? • Tensions between rational approach to decision making and the performance of decision making • Attempt to import approaches provokes dissonance between stated intent and ability to deliver in practice • Different communities arise that have different responses to the policy change- some explicit others less so

24. Key messages • Tying of expertise to the framework- • system willingness to accept process • ‘Junior clinicians’ excluded by former system welcomed new approach • Possibility of antagonism from more senior clinicians but not managers • Managers better versed in the performative aspects