Forum

Keele University

How to set priorities in health care

Darren Ashcroft reports on a meeting organised by the department of medicines management at Keele University and supported by the National Prescribing Centre which was held at Keele Hall on February 8

Introduction
Economic perspectives
Ethical issues
Implementation of guidance
Prescribing of costly medicines
Oxfordshire Priorities Forum
Clinical governance

Dr Ashcroft is prescribing strategy pharmacist at the department of medicines management, Keele University

Introduction

Opening the conference, Professor STEPHEN CHAPMAN (professor of prescribing studies, Keele University) explained that the aim of the meeting was to examine how priorities could be set in the face of competing patient requirements. The availability of more efficacious and expensive treatments required rational decision making, he said.

Professor Chapman estimated the likely costs associated with implementing the prescribing recommendations contained in the national service frameworks (NSFs) and guidance issued by the National Institute for Clinical Excellence (NICE) for a “typical” health authority (population approximately 250,000). These recommendations, if implemented fully, would lead to a substantial increase in spending on prescribed drugs within the health authority. And the costs would not be offset by disinvestment in, for instance, the usage of proton pump inhibitors or drugs of limited clinical value.

There were practical difficulties in identifying appropriate prescribing in primary care since prescribing analysis and cost (PACT) data did not link prescribing directly with morbidity or individual patients. Professor Chapman explained how the General Practice Research Database could provide a resource for monitoring prescribing in primary care, and suggested that in the future, newer initiatives such as MIQUEST, a general practice audit tool, would be used to monitor implementation of the NSFs and NICE guidance.

Economic perspectives

Professor JAMES RAFTERY (director of health economics, University of Birmingham) outlined the main practical difficulties in assessing the cost-effectiveness of medicines. In measuring and valuing benefits, problems arose in whether to use generic or disease-specific measures (eg, quality adjusted life years [QALYs] versus units on a clinical scale, such as serum cholesterol). The NICE was in favour of combining mortality and morbidity as in QALYs, but generic measures were a trade off between sensitivity and scope.

When looking at costs, whose point of view should be considered? The NICE did not consider costs attributable to society as a whole, but focused on costs that were likely to be borne by the National Health Service and personal social services. Most clinical trials were short-term and models were needed to extend beyond the trial period. Professor Raftery said that the time profile for cost effects might differ from that for benefits, and any savings, for example, through averted hospital admissions as a result of treatment, were likely to be achieved over the longer-term.

During 2000, 17 NICE health technology appraisals had been issued, of which nine had covered drug therapy. Cost per QALY data had been available for three of the nine drugs, with cost per life year estimated for three more. The remaining three appraisals contained no such information. Professor Raftery said that NICE judgments were not clearly related to the availability of cost per QALY data, and the decisions were based on multiple criteria.

Ethical issues

A system like the NHS might be said to have two purposes, which could come into conflict, said Dr SUE CHETWYND (lecturer, philosophy department, Keele University). The first was to provide a health care service for the benefit of society as a whole, and the second was providing health care for individual members of that society. These were not the same thing, since, at least in a situation of limited resources, benefiting society as a whole might mean deciding that it would be preferable to treat some health care problems rather than others, thus disadvantaging particular individuals by not offering them treatment because they did not suffer from the chosen problems.

The ethical problem with setting priorities in health care was that it brought into conflict two of the standard principles of medical ethics: justice and beneficence. Justice, as seen as equal treatment for equals, seemed to be at odds with the desire to do the best one could for the patient. Yet, in a situation of shortages, some decisions had to be made — and made on the grounds of justice or fairness, explained Dr Chetwynd.

Justice as equality of treatment appeared to be a principle that could be used when making macro-allocation decisions (allocation of the overall social budget to health, as opposed to education, social services, research, etc) and meso-allocation decisions (prioritising resources within the provision of health care on a regional or local level). There were problems, however, when it came to assessing equality. What factors were relevant to considering people equals? Even if what looked like a relatively objective measure, such as QALYs, were selected, there are problems with how these should be arrived at, or used.

Implementation of guidance

Ms HELEN CRITCHLOW (consultant pharmacist, National Prescribing Centre) spoke about implementing national guidance at a local level and outlined the content of a handbook that had been developed through collaboration between the NPC and the NICE. Ms Critchlow said that the preparation of high quality, evidence-based national guidance was only the first step in a much longer process. Effective dissemination at a national level was the next step, and local implementation was the crucial third step. Monitoring and feedback completed the process.

Ms Critchlow stated that any national guidance had financial and service implications requiring investment or disinvestment or both. The implementation process itself might also involve additional utilisation of resources. The resource assessment had to be built into formal planning processes locally. Existing groups should be used wherever possible in the implementation process. Ms Critchlow suggested that successful implementation strategies needed to employ a range of techniques to develop local understanding and ownership, and any plans needed to be realistic in terms of time-scale for full implementation. This would require a corporate approach within and between professions. The application and use of formal audit had to be realistic and needed to link into clinical governance frameworks wherever possible.

Prescribing of costly medicines

Dr JOHN MUCKLOW (consultant clinical pharmacologist, North Staffordshire Hospital NHS Trust) discussed the findings of a report entitled “The prescribing of costly medicines” that had been produced by a working party of the Royal College of Physicians. Dr Mucklow had acted as honorary secretary for the working party. He explained that the definition of a costly medicine included medicines with high acquisition costs but low prescribing volume (eg, human growth hormone for adults) and those with low acquisition costs that need to be prescribed widely (eg, statins).

The report presented 10 recommendations that include widening the debate on rationing and priority setting. Transparency of the process in setting priorities was important for the public to appreciate the difficulties that arose from the increasing unmet demand by finite resources. The early availability throughout the UK of medicines approved by the NICE should be guaranteed using a separate central stream of funds.

The report suggested that at a local level there was a need to develop understanding between primary and secondary care via district prescribing committees. The choice of medicines should be guided by developing a district formulary, and unnecessary or inappropriate prescribing should be discouraged to conserve budgets. The total cost of using a new medicine should be carefully anticipated and individuals should be identified who might authorise selective use. Developing shared care agreements and auditing the process and outcome were also crucial elements.

Oxfordshire Priorities Forum

Dr SIAN GRIFFITHS (director of public health, Oxfordshire health authority) outlined the structure, function and experiences from the Oxfordshire Priorities Forum, which has been in operation for about five years. The priorities forum was a subcommittee of the health authority which had originally been set up to deal with extra contractual referrals but had now moved on to tackle broader policy issues and provide clinical advice on new innovations and contentious issues.

An ethical framework had been developed consisting of three factors: effectiveness, equity and patient choice. The framework structured the discussions, ensured consistency in decision making and enabled articulation of the reasons behind the decisions, explained Dr Griffiths.

Clinicians submitting applications to the forum were asked the following three main questions:

Your service has a fixed envelope of resource. If you want to do something different, can it be done by substituting a treatment of less value?
If demand for your service is increasing, what criteria are you using to agree the threshold of treatment?
If you do not believe that it is possible to draw thresholds for care or substitute treatment, then which service might you give a smaller envelope of resource to in order for you to enlarge yours?

Patients were involved through the operation of an appeals process, open reporting, the development of discussion groups and the distribution of leaflets and statements that summarised the decisions that had been made. Dr Griffiths said, however, that there was a need for more public involvement.

Adopting a long-term view when it was this year's budget that was of primary concern was also difficult. Looking towards the future, there was a need to adapt to the changing role of health authorities and engage more closely with the primary care groups and trusts, which were likely to make their own choices.

Clinical governance

The key aims of the clinical governance agenda were to improve quality and safety of care by providing greater protection for patients, minimising risk, reducing poor performance and improving regulation explained Dr PHILIP LEECH (principal medical officer, Department of Health). Clinical and corporate governance could not be directly separated since both were focussed on establishing the right environment for care.

Some of the key mechanisms for change included improving access and convenience for patients, political expectation, cash for change, greater public involvement, better integration and co-ordination of services, and expanding the capacity in terms of workforce and infrastructure. Evidence-based practice, clinical audit and significant event monitoring would be built into clinical governance frameworks. The NSFs would set national standards and define service models for specific services or care groups. Programmes to support implementation would be put in place and performance measures would be established against which progress would be measured.

Minimising variation in standards and achieving acceptable care would lead to less accountability and greater autonomy, explained Dr Leech. The Commission for Health Improvement (CHI) would provide leadership for the development of clinical governance principles and provide an independent assessment of local clinical governance arrangements. The CHI would also review the implementation of NSFs and oversee incident inquiries, he concluded.