We need to talk about rationing

I was struck by the general appetite for a more open debate about rationing and priority setting at a recent conference on priority setting in health held by the University of Birmingham’s Health Services Management Centre (HSMC) and the Nuffield Trust.

The conference focused on the experiences of primary care trusts (PCTs) in making difficult choices. During the morning session HSMC’s Dr Suzanne Robinson introduced findings from research published by the Nuffield Trust that explored current priority-setting activities across English PCTs, while Dr Judith Smith from the Nuffield Trust led a session that considered how priority setting might fare under the new commissioning arrangements.

Much of the conversation in this regard focused on the enduring tension between local and national priorities. Most delegates seemed sceptical that the new clinical commissioning groups would have significantly more freedom and flexibility than the old PCTs, and that the NHS Commissioning Board was unlikely to remain the ‘hands-off’ organisation envisaged in the Health and Social Care Bill.

Disinvestment was the theme of the afternoon session. Dr Kerry Allen, HSMC, began by giving us a sneak preview of recent work conducted by the HSMC into decommissioning services for older people. 

The study, commissioned by the Association of Directors of Adult Social Services, explored the experiences of a range of organisations and individuals involved in care home closures. Mirroring the experiences of those in health care, respondents stressed the importance of communication, information, leadership, stakeholder involvement and coalition building.

Stakeholder involvement was also the theme of a talk by HSMC’s Dr Jo Ellins. As Dr Ellins explained, involvement comes in three forms:

• Information: in which information flows from the agency to the public;
• Consultation: in which information flows from the public to the agency; and
• Participation: in which information flows both ways between the public and the agency.

Within this framework, Dr Ellins identified some key factors for successful involvement:

• Set out clearly what the public is being asked to do;
• Make use of local networks and expertise;
• Have a clear rationale for selecting and inviting participants in your involvement activity (and for exclusions);
• Be clear with participants about other ways to input into the decision-making process;
• Communicate clearly how decisions have been made and where public views have been considered.

The final session of the day was led by Dr Sian Davies, St George’s Hospital. This session built on the learning and discussion from the day and explored what the various commissioning functions might look like in the future. It also explored some of the tensions of setting funding priorities under the new arrangements, and looked at what resources and skills decision makers would need in order to make difficult resource allocation decisions over the coming months and years.

Overall, as I mentioned earlier, I was struck by the general appetite for a more open debate about rationing and priority setting. Delegates often seemed frustrated about the lack of a public and political debate about these issues, feeling the buck was too often passed down the purchasing hierarchy to local commissioners, rather than confronted at a national level.

In this respect, one of the key questions for many delegates was how supportive the NHS Commissioning Board will be of local clinical commissioners when it comes to the tough choices ahead. In this, as in so many other issues, delegates were uncertain about whether the Government’s reforms signalled a substantive change in culture, or more of the same.