dm/hk © 2010 health services planning in the world class commissioning environment maximising...

DM/HK © 2010

Health Services Planning in the World Class Commissioning Environment

Maximising Patient Care Within Available Resources

Author: David Murray BSc MSc FFPHOperational Director, Consultant in Public Health & Honorary Senior Lecturer, PHAST & Imperial College London

Public Health Module

VenueDate

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Acknowledgements

Contributors:– Dr Richard Fordham – Senior Lecturer/Deputy Associate

Dean, Health Economics Group, University of East Anglia– Dr Peter Brambleby – Director of Public Health, North

Yorkshire & York PCT

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Aim

To explore the principles and practice of investment decision-making to maximise population health within available resources.

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Contents

1. The under-pinning concepts of health economics, including:– The economics perspective– Key economic principles – efficiency & equity

2. Information and evidence on costs and benefits:– Measurement of costs & benefits– Methods of economic evaluation – e.g. cost-effectiveness studies

& analyses

3. Practical methods of resource allocation/investment decision-making in health, including:– Resource allocation formulae– Programme budgeting & marginal analysis (PBMA)– Priority setting – e.g. multi-criteria analysis (MCA)

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1. Health Planning, Investment Decision-Making, & Health Economics

Investing in health

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Health Planning & Investment

• Consideration of comprehensive range of health improving interventions:– Promotion of health– Prevention of disease– Screening– Diagnosis– Treatment/management– Rehabilitation

• Need - Demand - Supply

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Policy Context

• Policy context:– WCC competence 6 – Prioritise investment according to local needs,

service requirements, & the values of the NHS.– WCC competence 11 – Make sound financial investments to ensure

sustainable development & value for money. – Care Quality Commission: PCT Commissioning standards – Domain 2:

Clinical & cost effectiveness

• Combined perspective – health planning & health economics

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"World Class Commissioning“ (2008)

• "Investment decisions will be made in an informed and considered way, ensuring that improvements are delivered

within available resources" (DH, 2007a)

• PCTs will be able to: "Prioritise investment by having a thorough understanding of the needs of different sections of the local population ...

• Make confident choices about the services that they want to be delivered, and acknowledge the impact that these choices may have on current services and providers..."

(DH, 2007a)

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NHS Confederation Guidance to PCTs (2008)

• The 'primacy of prioritisation must be a fundamental principle of public sector resource allocation'.

• A 'whole system' approach must be taken which takes account of and is applicable to all health service delivery in a given area

• Avoid unintended consequences and opportunity costs associated with narrower priority setting or decision making processes

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2. Health Economics Perspective

A room with a different view

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Source: Rupert Fawcett Cartoons

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Economics

Greek: oikonomos, "one who manages a household" ..oikos, "house"

and nemein, "to manage"

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Group Discussion - Household Investment Decision-making

• Think of 2 or 3 recent decisions you have taken to make a substantial purchase in your household

• Discuss how you came to the decision to make the purchase & how you chose the particular product

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Health Economics

• A framework for the systematic consideration of costs & benefits across society in support of priority setting/ investment decision-making

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Finance & economics

FINANCE/MONEY = measure & store of value, means of exchange (usually reflected in price)

ECONOMICS = what is produced; how resources used up in producing it; how these products are exchanged and by whom

MONEY is only a currency!

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What you already know about economics (but might have been totally unaware of !)

• Humans are quite ‘rational’ economic beings (most of the time) ..

• We all satisfy our own needs rationally… ‘maximise our own personal ‘utility’ subject to a resource constraint’

• We want to maximise gain and minimise pain!• But it’s not just about self-interest! eg. altruistic or

communal gifts• Why should society be any different? – it’s only the sum of

its parts

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Health Economics Perspective 1

• Acceptance of resource/budget limitations• Scope – societal vs public sectors vs NHS• Long-run timeframe• Cost vs price• Opportunity cost – all investment choices & uses result in other

lost opportunities• Demand = willingness & ability to pay at a given price

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Health Economics Perspective 2

• 2 concepts of efficiency:– Technical: Doing things well/at least cost for a given output

at a given quality– Allocative: Doing the right things to maximise benefit from

available resources• Marginal analysis – measurement of costs/savings & benefits

additional to the current baseline• Equity – consideration of the spread/allocation of fair/ethical

costs & benefits across society

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3. Costs & Benefits

Weighing it up

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Weighing up the input & outputs in alternative uses of resources ...

Resources Outcomes

?

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Group Discussion – Resources & Benefits

• Briefly discuss the ‘resources’ & ‘benefits’ we would need to weigh-up in introducing a ‘hospital at home’ service

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Economic approach

• Weighing up the costs and the benefits of alternative courses of action (Drummond, 1987)

• Costs (full resources) to whom?• Benefits…to whom? Concern with equity.• Divergence of personal and social costs• Wider scope of benefits in public health

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Production Costs & prices

• Fixed cost – constant over a period of time regardless of workload

• Semi-fixed/stepped cost – constant within given production limits (e.g. additional staff)

• Variable cost – vary in proportion to workload• Sunk cost – investment that cannot be re-invested

• Price = cost + profit/surplus

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Costs

• Total cost• Unit cost = 1 unit/patient• Average cost = total cost/N• Marginal cost = cost of producing one additional unit• Cost curves• Opportunity cost = foregone opportunity to produce the next

best alternative use of resources

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Economies of scale

• Constant returns to scale • Diseconomies and economies of scale

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Costs

• Direct cost – e.g. health care staff time & consumables• Indirect costs – e.g. catering• Overhead costs – e.g. management, heating• Intangible costs – e.g. pain, inconvenience

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Health Benefits

• Survival/death• Treatment• Cure• Cases/infections prevented• Length of life• Quality of life• Function

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Societal Benefits

• Productivity:– employment– education– caring

• Participation (e.g. politics, arts)• Independence

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4. Efficiency & Equity

Doing the right things, well, & for all the right people

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Technical efficiency - Inputs and outputs

• Maximise output subject to budget/cost limit or minimum• Minimise costs subject to a fixed or maximum level of output• No resources wasted in production of a given product at an

accepted quality

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Productivity

• Measure of technical/productive efficiency• Amount of output per unit input in producing a given

product e.g:– Factory hours to make a product– Number of products produced by a factory per day– Patients treated per hour/per clinic

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Allocative efficiency

• Allocative efficiency is where organisation is producing a combination of goods that maximises the overall level of satisfaction or welfare of the population of interest

• Global efficiency – allocative efficiency across all productive activities in society as whole e.g. education, health, welfare benefits, industry, etc

• Where no further reallocation of resources at the margins of production could improve social welfare function (=∑individual welfare functions) – i.e. social welfare is maximised

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Pareto optimality

• The theoretical condition as a result of perfect global efficiency, where it is impossible to make one person better off without making someone else in society correspondingly worse off is called a Pareto optimal allocation of resources– How do we know when NHS organisation(eg. PCT) is

allocatively efficient?

– What type of market conditions are likely to lead to the

allocative efficiency?

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Ethics, equity, & economics

• Ethics - theories of social justice/fairness• Equity - treatment according to need/access/ demand/use• Economics – equity (distribution/shares of benefit) vs efficiency

(total benefit)

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Common equity dimensions

• Age• Gender• Sexuality• Geography• Socio-economic status• Ethnicity• Religion• Disease/condition• Severity/prognosis

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Equity not necessarily = equality

• Equity concerned with ‘fairness' ‘justice’ (i.e.ethical theories)• May not necessarily be identical to equality (e.g.minimum

standards of care, ‘positive’ discrimination) due to taking account of need

• However, equity usually synonymous with equality of something (e.g. right to equal opportunity to access)

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‘Definitions’ of equity

• Equal ‘chance’ of treatment - lottery• Equal expenditure per capita - geography• Equal expenditure/resources for equal ‘need’ (i.e. weighted

capitation e.g.‘premature’ mortality)• Equal access (opportunity to use) for equal need (e.g. equal

waiting time per ‘condition’) & physical/geographic access• Equal utilisation for equal need (e.g. equal length of stay

per ‘condition’)• Equal treatment rates for equal need• Equal ‘health’

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Equity : Efficiency Trade-off

• Explicit equity weighting remains controversial unless considering ‘total social welfare’ rather than economic efficiency alone

• Access to primary/secondary/tertiary care (e.g. GP vs NICU)• NICE willingness to pay Cost per QALY for treatments

prolonging life in terminal cancer conditions• Targeted out-reach initiatives for ‘hard to reach’ groups

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5. Economic Evaluation

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Key Methods of Economic Evaluation

• Cost Consequence Analysis• Cost-Minimisation Analysis• Cost Effectiveness Analysis (CEA)• Cost-Utility Analysis (CUA)• Cost-Benefit Analysis (CBA)• Modelling

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Length & quality of life 1

• Length of life– Mortality (numbers, rates, SMRs)– Life expectancy – Healthy life-years (eg. QALYs)– Disability-free life years (eg. DALYs)

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Length & quality of life 2

• Measures of (Health-related) Quality of life:– Numerous QoL measures (generic & disease specific)– SF-36– Nottingham Health Profile– Symptom Checklist– Hospital anxiety and depression scale

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Quality Adjusted Life Years (QALYS)

Adjusts data on quantity of life years saved to reflect a valuation of the quality of those years.

If healthy: QoL = 1.0

If dead QoL = 0

e.g. 5yrs survival gain at ½ QoL = 5 X 0.5 = 2.5 QALYs

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Disability Adjusted Life Years (DALYS)

• Measure of burden of disease adjusted for lost function/productivity (WHO)

• World Bank, Global Burden of Disease (1996)• Years of life lost due to premature death + years lived with

disability (mortality + morbidity)• Better reflection of burden due to chronic disease rather than

due to common causes of death

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Issues in Economic Evaluation 1

• Taken up by research community, good journals, etc• Used nationally - e.g. NICE• Still ignored by local decision-makers• Suspicion from clinicians• Resistance from public

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Issues in Economic Evaluation 2

• Lack of good cost data to use• May not capture all the benefit dimensions required by

decision makers• Controversy about methods and values used

in techniques

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Steps in costing

1. Defining the perspective/viewpoint

2. Identification of costs to include in the appraisal

3. Measurement of the resources used (how much of each item?)

4. Valuation of the resources used

(what does each item cost?)

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Identifying costs

• A full identification of important and relevant costs should be provided and any omissions justified– Trade-off between time and effort involved in collection and potential

impact on results– What are the key cost drivers likely to be?

• Include free costs e.g.volunteer and patients’ leisure time and donated clinic space

• Not all costs that are identified have to be measured and valued

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Measure how much of each item used?

• Number of medical visits, tablets consumed, hours of staff time…

Sources include:• Health insurance accounting systems• Computerised hospital and primary care records• Reports from health professionals, patients and carers• Standards (guidelines, best practice) - medical notes often assumed most accurate

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What does each item cost?

• Use existing market prices where appropriate

• Unit costs from local sources of national statistics:- NHS reference costs and PbR tariff- BNF drug costs- PSSRU health and social care services

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Valuation(Unit prices)

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Example: cost-effectiveness of splinting and surgery for patients with Carpal tunnel syndrome

Identification and measurement

*mean (standard deviation);

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Comparing costs

Korthals-de Bos et al, Surgery is more cost-effective than splinting for carpal tunnel syndrome in the Netherlands: results of an economic evaluation alongside a randomized controlled trial, BMC Musculoskeletal Disorders 2006, 7:86

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Further methodological issues

• How long to track costs for? • Discounting• Annuitisation of capital assets• Purchasing power parity (not exchange rates)• Dealing with shared costs/overheads (light, heat)• Uncertainty and sensitivity analyses• Transfer payments • Drummond appraisal checklist

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Cost Minimisation Analysis

• Comparative costing of alternative treatments which are proven or assumed to have equivalent outcome in order to identify the least cost option

• No outcomes measurement

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Cost Consequence Analysis

• Collation of information of cost & outcome consequences of alternative interventions, but without calculation of cost effectiveness ratios

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Cost-consequences analysis

Coast J. 2004. ‘Is economic evaluation in touch with society’s health values?’ BMJ 329: 1233-12236

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Cost Effectiveness Analysis (CEA)

• Comparison of alternative interventions with same outcomes, using non-monetary natural units of outcome measurement – e.g. survival, life years gained, reductions in units of BP, cardiac events prevented, tumour response

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Cost effectiveness of shared care and nurse practitioner care

Nurse Care

Shared Care

Incremental costs and benefits

NHS Cost (£)

5343 6319 6319-5343=976

No. Patients benefit

202 220 220-202=18

Average cost-effectiveness

26.45

(5343/202)

28.72

(6319/220)

Marginal CE 54.2(976/18)

Torgerson and Spencer, BMJ 1996;312:35-36

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Cost Utility Analysis (CUA)

• ‘Utility’ = positive well-being• Comparison of alternative interventions, using generic non-

monetary valuation units of outcome measurement – e.g. quality adjusted life years (QALYs)

• Requires research to establish value of outcomes.• Allows comparison of interventions achieving different health

outcomes (e.g. prevention vs treatment, CHD vs cancer)

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Cost Benefit Analysis (CBA)

• Comparison of alternative investments where both costs & benefits are measured in monetary terms, to calculate a net cost : benefit sum

• Allows comparison across widest range of investments/interventions beyond health – e.g. education vs health

• Requires monetary valuation of all benefits

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Decision analytic modelInitial three months Next three-month cycles

Death

DeathDeath

WC75WC75

WC50WC50

NCNC

WC75

WC50 [+]

NC [+]

Standard Tx

Death

DeathDeath

WC75WC75

WC50WC50

NCNC

WC75

WC50 [+]

Switch to Standard TxStandard Tx

DeathDeath

NCNC

NC

No switch

Switch due to AE to Standard Tx

Rufinamide (RUF)

Topiramate (TPM) [+]

Lamotrigine (LTG) [+]

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Practical Approaches to Resource Allocation

1. Population capitation formulae2. Programme budgeting & marginal analysis3. Priority setting/investment decision-making

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NHS Capitation Funding

• Formula driven funding (based on PCT population)

• Weighted capitation (age, deprivation etc) (revised 2003)

• Gets PCTs onto a level playing field wrt. population need (in theory!)

• ‘PCTs make decisions on investing these ‘cash’ resources

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The underlying principle

• The objectives of the weighted capitation formula are to determine PCTs' target shares of available resources to enable them to commission similar levels of healthcare for populations with similar healthcare need, and to reduce avoidable health inequalities (eg. cancer treatment)

See: Resource allocation: weightedcapitation formula (sixth edition) DH 2008

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Four elements are used to set PCTs’ actual allocations

a) PCT populations adjusted for:- (i) their age distribution(ii) additional need over and above that relating to age (ie. deprivation)(iii) unavoidable geographical variations in the cost of providing services (themarket forces factor (MFF)

b) Recurrent baselines – which represent the actual current allocation which PCTs receive

c) Distances from targets (DFTs) – which are the differences between (a) and (b)

d) Pace of change policy – which determines the level of increase which all PCTsget to deliver on national and local priorities and the level of extra resources tounder target PCTs to move them closer to their weighted capitation targets.

NB. PCTs do not receive their target allocation immediately but are moved to it over a number of years.

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Investment priority setting

Context

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Worldwide: WHO-CHOICE‘CHOosing Interventions that are Cost Effective’

“Top 10” buys include:• speed bumps to reduce traffic injuries;• insecticide-treated bed nets to prevent malaria;• increased taxes on tobacco• Directly Observed Therapy short course (DOTS) for TB;• birth attendants;

• salt fluoridation to prevent dental caries

See: http://www.who.int/choice/en/

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Cancer prioritisation and cost in UK

NHS Budget Impact

Saving 2

No additional resources required 3

Cost < £10m 11

Cost between £10-20m 6

Total 22

Cost per QALY

< £20K 4

£20- £30K 3

> £30K 2

Cost per LYG

< £20K 8

£20- £30K 4

> £30K 1

Total 22

35 Cancer technologies appraisals by NICE to May 2005

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Potential resistance to economic decision making!Williams and Bryan (2007) identify the following reasons why policy makers do

not use economic studies:• Transparency: policy makers simply do not understand the study or

methods used;• Validity: policy makers do not believe the study outcomes;• Relevance: the study does not provide information relevant to decision-

making context, such as the impact on local budgets;• Clarity: the presentational style is inaccessible (see 1);• Comparability: variations in methods make comparing

Interventions difficult;• Affordability: policy makers have insufficient budget to commission

economic studies;• Objectivity: policy makers question the independence of those undertaking

the work;• Philosophy: policy makers reject the principles underlying

economic evaluationWilliams I, Bryan S (2007) ‘Cost-effectiveness analysis and formulary decision making in

England: findings from research’, Social Science and Medicine 65: 2116–2129

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Disinvestment vs Always expecting more?

‘’a culture of expecting more resources rather than having to make trade-off decisions and reallocations’’

Mitton and Donaldson (2004)

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Experience of decommissioning

A recent survey has shown that the total value of services decommissioned across the 60 PCTs that responded was £14m - a tiny fraction of the £70bn PCTs spend each year.

The majority of Trusts (40 out of 60) said they had not decommissioned anything!

(HSJ, October 2008)

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Process Benefits of Investment Decision-making Tools

• Promoting the bigger picture• Soft intelligence• Clinical & expert advice• Clinical & organisational engagement• Ownership & commitment to implement agreed changes

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Programme Budgeting Marginal Analysis (PBMA)

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PB vs Finance Information – Alternative Dimensions

• Financial/accountancy - inputs:– Functional/organisational (e.g. GPs vs hospital)– Funders– Debtors– Staff/employees

• PB – combining resource information with that on:– Population needs/outcomes

– Strategic goals (e.g. prevention vs treatment)

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Questions to ask

• Do you know where the NHS money in your local health economy goes at present, by age group, disease group, prevention spend or clinical specialty?

• Do you have adequate data on patient outcomes and satisfaction, (ie what good that investment of resources is doing, in these areas?)

• Do you have any evidence (or even a gut feeling!) of where those same resources could be moved from one area of activity to another to generate greater health gain?

• Can you list, in priority order, where new investment should go first in order to do the greatest good for the client group or population you look after?

• Is it reasonable to try to engage your local clinicians, commissioners and public in discussions about doing things differently without such information?

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If your answer to any of these questions was “No”, then Programme Budgeting and Marginal Analysis

(PBMA) may be a technique that can help!

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Definitions

• Programme budgeting is a retrospective appraisal of resource allocation broken down into meaningful programmes, with a view to tracking future resource allocation in those same programmes

• Marginal analysis is the appraisal of added benefits and added costs when new investment is proposed (or lost benefits and lower costs when disinvestment is proposed), in an incremental way

Mooney G, et al, Choices for Health Care, MacMillan, 1986

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It is rocket science!• Its first major application was

not in health care but in the US Department of Defence in the 1960s.

• Cost accounting tool that could display, over time, the deployment of resources that supported specific military objectives, like wars overseas, the support of NATO or defence of the homeland, rather than the conventional budgetary approach of tanks, missiles or diesel fuel.

• Allocation of new resources, or shifts between budgets, could be judged on their relative contribution to the main objectives – a much more meaningful way of making decisions.

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Right for health?

• Outcome based funding Instead of looking at the investment in a particular hospital or drug budget, the focus becomes “reducing heart disease death rates”, “improving indicators of child health”, “reducing the burden on family carers of patients with senile dementia”, etc

• The focus is on objectives - maximising health gain by deploying resources to best effect

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Marginal Analysis

• What would you do with 10 % more on your annual budget that you can’t do now? ‘WISH LIST’

• What would you cease to do if you had to make do with 10% less? ‘HIT LIST’

• So those things on your HIT LIST have a lower MB at current levels of activity than those things on your WISH LIST

• If you can’t think of anything with more benefit or prefer not to give up anything currently to carry on what you’re doing then you are probably allocatively efficient!

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PBMA: eight steps

1. Choose a set of meaningful programmes to work with – perhaps age groups, disease groups or clinical directorate groups

2. Identify current activity and expenditure in those programmes (programme budgeting). Try to account for the total budget, to avoid the risk of omissions but double-counting

3. Be creative - consider improvements and linkages in pathways and patterns of care, within and between these programmes

4. Weigh up extra costs and increased benefits (or decreased benefits and reduced costs) of the improvements you have thought of (marginal analysis)

5. Consult widely - there may be options, trade-offs and value judgements to explain

6. Decide - and make that decision public7. Make the change happen! This is the essence of management8. Evaluate progress - check that the anticipated costs, savings and

outcomes materialised in practice, then repeat the exercise

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PBMA: CHD programme

• Population lifestyle social marketing programme• General Practitioner Quality Outcome Framework Coronary

Heart Disease programme• Statins• Rapid access chest-pain clinics• Revascularisation• Cardiac rehab

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PB Tools & Resources

• DH PB tool: 2008/09 release• NHS National Knowledge Centre – greater functionality

linking with need/epidemiology/PH area data• YHPHO PCT Spend & Outcomes Factsheets & Tool (SPOT)• DH. Programme budgeting guidance manual. Revised 23

May 2007• Peter Brambleby, Andrew Jackson, J.A. Muir Gray

Programme-based decision- making for better value healthcare: The 2nd annual population value review. October 2008. NHS Knowledge Service/DH

• Ruta D et al. (2005) ‘Programme budgeting & marginal analysis: bridging the divide between doctors & managers’. BMJ 330: 1501-3

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Spend & Outcome Factsheets & Tool (SPOT) – Kirklees [YHPHO]

Spend and Outcome relative to other PCTs in England

Soc Pois

Mat,Neo

Trauma

Musc Skin,Hlth Gastro

Dent

RespCirc

Hear VisionNeuro

LD

MHEnd

Blood

Canc

Inf,GU

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

-2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5

Spend per head Z Score

Hea

lth

Ou

tco

me

Z S

core

Lower Spend, Better Outcome

Lower Spend,Worse Outcome

Higher Spend,Worse Outcome

Higher Spend,Better Outcome

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Multi Criteria Analysis (MCA)

• Point scoring system that takes account of multiple criteria:– Criteria are locally determined– Weighted to give precedence to those of most relevance– Allows alternative interventions/services/programmes to be scored

against these criteria

• Divide cost by point score to give ‘cost-effectiveness’• Compile a ranking to guide decision making

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The Process

Define the criteria

Weight the criteria

Cost the options

Produce ranking in order of cost-effectiveness

Score the options

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Defining the Criteria

• Derived from objectives of service• Generic not specific

• “Improves rehabilitation and after-care” rather than “employs more district nurses”

• Should be identifiable and measurable • E.g. life-years gained, effectiveness estimate

• Need to be “mutually preference independent”• Able to assign preferences against one criterion

independently of preferences against other criteria

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Deriving the benefit criteria What Do I Want in a New Car?

• Safety• Style• Fuel economy• Space• Acceleration• Reliability• Comfort/accessories• Etc etc...

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Weight the Criteria

• Are some criteria more important than others?

• Safety• Style• Fuel economy

50%20%30%

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Score Each Car against Criteria

Score Weight Weighted ScoreSafety 7

Style 10

Fuel economy 6

1.0

0.5

0.2

0.3

3.5

2.0

1.87.3

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...Do the same for the alternative and rank them by Cost-Effectiveness

Car £ per point

Volvo £1,642

MX3 £2,055

VW £5,340

Skoda £14,310

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Example Criteria Weights1. Addressing inequalities 14

2. Whole person approach, choice 6

3. Fit with national/local objectives 10

4. Needs assessment 14

5. Size of population who will benefit 5

6. Effectiveness for patients and/or population 19

7. Sustainable benefits 7

8. Preventive, self-help 9

9. Accessibility 9

10. Feasibility 7

TOTAL 100

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Effectiveness, Efficiency, & Equity - Worked Example (Brambleby) [1]

• Our mission is to secure the most effective, equitable and efficient services for our population, within the resources entrusted to us.”

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Effectiveness, Efficiency, & Equity – Worked Example (Brambleby) [2]

• Cancer X - universally rapidly fatal if not treated• Incidence of “X” is 300 new cases per year • 3 possible treatment packages, A, B & C• Good trial evidence on typical outcomes and typical costs• Newly enhanced budget is £1,500,000

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• Treatment options:– “A” adds 3 years of life @ £5,000(current treatment) – “B”adds 5 years of life @ £6,000– “C”adds 6 years of life @ £15,000

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• Equity consideration – number of people with Cancer X in the population benefiting from treatment:– A @ £1,500,000/£5,000 = 300 people– B @ £1,500,000/£6,000 = 250 people– C @ £1,500,000/£15,000 = 100 people

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Therapy Cost (£)

Effectiveness (years added per patient)

Equity (patients treated from budget)

Efficiency (total years gained from budget)

A 5,000 3 300 900

B 6,000 5 250 1250

C 15,000 6 100 600

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• A is the most equitable; everyone has access• B is the most efficient; maximises total population health gain

from fixed budget• C is the most effective• A & B satisfy the “utilitarian” ethic• C satisfies the “Hippocratic” ethic

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Incorporating cost-utility (Brambleby) [8]

LoL x QoL QALYs Population Health Gain (QALYs)

A 3 x 0.7 2.1 2.1 x 300 = 630

B 5 x 0.5 2.5 2.5 x 250 = 625

C 6 x 0.8 4.8 4.8 x 100 = 480

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Seven key organisational challenges to PBMA & priority setting

• Time (having enough of it!); • Good data; • Disinvestment incentives; • Identifiable programme budgets; • Outcome measurement; • Public involvement;• Organisational behaviour.

Mitton and Donaldson (2004)

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Organisational behaviour

• Formal v. informal process going on?• ‘Transactions costs' to participants are critical to success of

PBMA (Jan, 2000)• Individuals will only engage with PBMA if there are

opportunities to expand/protect their own budgets and/or restrict the expansionary tactics of rival claimants!

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Priority setting - summary

• Prioritisation by order of cost-effectiveness ensures best value for money from public funds

• Weighted benefit score captures all dimensions of ‘benefit’ in a single index

• Combining score with resource use data allows a crude cost-effectiveness ratio to be calculated

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Participant Evaluation

• Lilac = What did you learn?

• Yellow= What worked well for you in the workshop

• Blue = Is there anything you would do differently, if so, what and how?

• Green = What are your future needs?

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