Rationing in the fiscal ice age

How reforms hamper priority-setting in health care: an interview study with local decision-makers in London

The fair allocation of scarce resources for health remains a salient topic in health care systems. Approaches for setting priorities in an equitable manner include technical ones based on health economic analyses, and ethical ones based on procedural justice. Knowledge on real-world factors that influence prioritisation at a local level, however, remains sparse. This article contributes to the empirical literature on priority-setting at the meso level by exploring how health care planners make decisions on which services to fund and to prioritise, and to what extent they consider principles of fair priority-setting. It presents the findings of an interview study with commissioners and stakeholders in South London between 2017 and 2018. Interviewees considered principles of fair prioritisation such as transparency and accountability important for offering guidance. However, the data show that in practice the adherence to principles is hampered by the difficulty of conceptualising and operationalising principles on the one hand, and the political realities in relation to reform processes on the other. To address this challenge, we apply insights from the policy and political sciences and propose a set of considerations by which current frameworks of priority-setting might be adapted to better incorporate issues of context and politics.

Successfully changing the mode of regulation in clinical priority setting: how organisational factors contributed to establishing the Norwegian priority guidelines for specialist health care services

This article investigates factors that contributed to the successful introduction of 33 priority guidelines for Norwegian specialist health care from 2008 to 2012. The guidelines constituted an important step in changing the regulation of clinical priority setting from largely self-regulation by medical professionals to a more centralised and hierarchical form, and therefore, resistance from the medical profession was expected. My focus is on organisational factors within the project that developed the guidelines, using policy documents and project documents as the main source of data. I find that the project was characterised by a high level of autonomy in terms of how it was organised and the actors included, with significant capacity for action in terms of both structure and personnel, and a broad inclusion of affected actors. The priority guideline project was dominated by medical professionals, and its organisation did not represent a radical break with established traditions of medical professional self-regulation. Although organisational autonomy, action capacity and broad inclusion were clearly of importance, the project's compliance with historical traditions and norms of medical governance stands out as the key factor in understanding the successful establishment of the priority guidelines.

Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review

Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.

The health cost of reducing hospital bed capacity

In the past two decades, most high-income countries have reduced their hospital bed capacity. This could be a sign of increased efficiency but could also reflect a degradation in quality of care. In this paper, we use repeated cross-sections on mortality and staffed hospital beds per capita in all 21 Swedish regions to estimate the potential death toll from reduced bed capacity. Between 2001 and 2019, mortality and beds decreased across all regions, but regions making smaller bed reductions experienced on average greater decreases in mortality, equivalent to one less death per three beds retained. This estimate is stable to a wide range of specifications and to adjustment for potential confounders, which supports a causal interpretation. Our results imply that by providing one more bed, Swedish health care could produce about three quality-adjusted life years (QALYs) at a cost of SEK 400,000 (∼US$40,000) per QALY. These findings could be informative about the marginal productivity of health care and support the credibility of empirical work attempting to estimate the opportunity cost of funding new healthcare interventions subject to a constrained budget.

Factors that shape the successful implementation of decommissioning programmes: an interview study with clinic managers

BACKGROUND

As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization.

METHODS

Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated.

RESULTS

The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process.

CONCLUSIONS

From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

'Real-world' priority setting for service improvement in English primary care: a decentred approach

This article develops an analysis of population-level priority setting informed by Bevir's decentred theory of governance and drawing on a qualitative study of priority setting for service improvement conducted in the complex multi-layered governance context of English primary care. We show how powerful actors, operating at the meso-level, utilize pluralistic and contradictory elements of complex governance networks to discursively construct, legitimize and enact service improvement priorities. Our analysis highlights the role of situated agency in integrating top-down, bottom-up and horizontal influences on priority setting, which leads to variation in local priorities despite the continuous presence of strong hierarchical influences.

Decommissioning in a local healthcare system in Sweden: responses to fiscal stress

BACKGROUND

Drawing on the literature on cutback management, this article deals with healthcare decommissioning in times of austerity. Politicians and decision-makers are typically reluctant to decommission healthcare, and if they do, the public generally reacts strongly towards reductions in service supply. Despite this, comprehensive decommissioning does take place, though empirical knowledge about its effects and economic sustainability is limited. To further the understanding of healthcare decommissioning, this paper aims to introduce the concepts of cutback management into the research on healthcare decommissioning, and apply its components to an empirical case of comprehensive decommissioning. In doing so, the study analyses whether decommissioning measures can be expected to generate long- or short-term economic payoff, and considers what other effects they might have on the healthcare system.

METHOD

We developed a theoretical framework that enabled us to investigate the measures through which a local healthcare system in Sweden, region Dalarna, responded to an acute fiscal crisis in 2014, and what effects these measures are likely to generate. The method used was a deductive content analysis of Dalarna's decommissioning program, containing 122 austerity measures for saving 700 million Swedish Krona (SEK).

RESULTS

Dalarna's local decision-makers responded to the fiscal crisis through a combination of operational cuts (20% of undertaken measures), programme cuts (42% of undertaken measures), and structural reforms (38% of undertaken measures). The instruments most commonly used were increased patient fees and the merger of service facilities. By relying foremost on programme cuts and structural reforms, Dalarna adopted the measures most plausible to have moderate or long-term economic payoffs. Successful implementation, however, may be challenging and difficult to evaluate.

CONCLUSIONS

Healthcare politicians and decision makers have better potential to stabilize their long-term economic situation if they rely on responses such as operational cuts, programme cuts and structural reforms, as opposed to across-the-board cuts and cuts in investment and capital expenditures. However, with economics being only one important factor for sustainable healthcare systems, further studies should investigate how these measures affect important principles, such as equal healthcare distribution and access.

TRIAL REGISTRATION

Not applicable.

Cuts without conflict: The use of political strategy in local health system retrenchment in Sweden

Disinvestment in health services is seen as challenging by decision-makers as the public usually reacts strongly to rationing and retrenchments. Drawing on the literature on welfare state retrenchment - the reduction of public expenditure by cutting costs or spending - this article explores the development and implementation of a comprehensive retrenchment programme in one local health system in Sweden (a so-called region). According to theory, retrenchments are both electorally risky and institutionally difficult. Nonetheless, they take place and in the local health system we investigate, without too extensive public protest and without decision-makers having to resign. The main question in this qualitative study is: why and how was it possible to make such comprehensive retrenchments despite being unpopular and facing many political and institutional barriers? Interviews with 18 local politicians and public servants were carried out between January 18 and April 3, 2017, and analysed from the perspective of political strategy. They showed that the serious budget deficit, and a shared understanding of what the region's problems were, are important explanations for why the retrenchment programme was possible to develop and implement. Based on a thorough internal review of the health system, a crisis discourse developed which partly depoliticized the retrenchment programme. Justification and framing are keys to how it was possible. The retrenchment programme was justified by arguing that current service provision exceeded that in comparable regions, and framed as necessary saving the local health system and enhancing quality. Important strategies were thus to redefine the retrenchments and to blame-share, the latter through politicians and public servants claiming responsibility together after involving the clinic managers. In sum, our study shows that the retrenchment literature and theories on political strategy may be fruitfully applied to the health-care sector as well. By studying the local level, our findings contribute to the retrenchment literature, indicating that political strategy at the local level is more about justification and blame sharing, than blame avoidance.

Rationing for medicines by health care providers in Indonesia National Health Insurance System at hospital setting: a qualitative study

Background

Universal Health Coverage (UHC) in Indonesia is planned to be fully implemented in 2019 through the National Health Insurance (NHI) launched in January 2014. However, limited financial resources cause health care providers (HCPs) to perform rationing in providing medicine services. The purpose of this study was to analyze rationing strategies performed by HCPs for potentially beneficial essential medicines due to financial constraints and other reasons in the Indonesian NHI Plan and evaluate its fairness.

Methods

A qualitative study was conducted to find out the rationing performed by 24 HCPs in NHI medicine services at hospital setting. Research methods included semi-structured interviews with eight physicians, eight pharmacists and eight nurses, and observations of prescriptions undergoing dispensing process. Respondents were purposively selected, and interview results were analyzed thematically. The strategies for rationing were categorized using the matrix developed by Maybin and Klein (denial, selection, delay, deterrence, deflection, and dilution), while contradictions in fairness were evaluated using the four conditions of accountability for reasonableness (relevance, publicity, appeals, and enforcement).

Results

The results showed that the most frequent rationing performed by physicians was dilution (to replace medicines with others which were perceived by physicians as less effective or less safe), denial (not to provide medicines not listed in the National Formulary and/or expensive medicine), and deterrence (to encourage patients to pay for medicine). Among pharmacists, the most frequently rationing performed was dilution (to reduce the amount of medicines), denial, and deterrence as performed by physicians. Almost no rationing strategy was performed by nurses. No formal procedure was available to guide the rationing. The rationale for rationing strategies, especially for non-clinical reasons, was often not communicated to patients, and there were few opportunities for patients to appeal the rationing strategies applied to them. There was no difference between the government and private hospitals in the rationing strategies adopted.

Conclusions

Although rationing strategies were facilitating the implementation of National Formulary, they potentially raise problems related to the principles of medical ethics and distort a national health system’s ability to progress towards UHC. If performed in the more standardized decision-making process, rationing would be of great benefits to patients and the system. Guidance for more explicit, fair and transparent of rationing should be developed at the hospital level.

Reports of rationing from the neglected realm of capital investment: Responses to resource constraint in the English National Health Service

Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area.

Past, present and future challenges in health care priority setting

Purpose Current conditions have intensified the need for health systems to engage in the difficult task of priority setting. As the search for a "magic bullet" is replaced by an appreciation for the interplay between evidence, interests, culture, and outcomes, progress in relation to these dimensions requires assessment of achievements to date and identification of areas where knowledge and practice require attention most urgently. The paper aims to discuss these issues. Design/methodology/approach An international survey was administered to experts in the area of priority setting. The survey consisted of open-ended questions focusing on notable achievements, policy and practice challenges, and areas for future research in the discipline of priority setting. It was administered online between February and March of 2015. Findings "Decision-making frameworks" and "Engagement" were the two most frequently mentioned notable achievements. "Priority setting in practice" and "Awareness and education" were the two most frequently mentioned policy and practical challenges. "Priority setting in practice" and "Engagement" were the two most frequently mentioned areas in need of future research. Research limitations/implications Sampling bias toward more developed countries. Future study could use findings to create a more concise version to distribute more broadly. Practical implications Globally, these findings could be used as a platform for discussion and decision making related to policy, practice, and research in this area. Originality/value Whilst this study reaffirmed the continued importance of many longstanding themes in the priority setting literature, it is possible to also discern clear shifts in emphasis as the discipline progresses in response to new challenges.

Priority Setting: Right Answer to a Far Too Narrow Question? Comment on "Global Developments in Priority Setting in Health"

In their recent editorial, Baltussen and colleagues provide a concise summary of the prevailing discourse on priority-setting in health policy. Their perspective is entirely consistent with current practice, yet they unintentionally demonstrate the narrowness and moral precariousness of that discourse and practice. I respond with demonstrations of the importance of 'interrogating scarcity' in a variety of contexts.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

Implementing priority setting frameworks: Insights from leading researchers

In spite of a substantial literature developing frameworks for policymakers to use in resource allocation decisions in healthcare, there remains limited published work reporting on the implementation or evaluation of such frameworks in practice. This paper presents findings of a targeted survey of 18 leading researchers around the implementation and evaluation of priority-setting exercises. Approximately one third of respondents knew of situations where recommendations of priority-setting exercises had been implemented, one third knew that recommendations had not been implemented and the final third responded that they did not know whether recommendations had been adopted. The lack of evidence linking the implementation of priority-setting recommendations to equity and efficiency outcomes was highlighted by all respondents. Features identified as facilitating successful implementation of priority-setting recommendations included having a climate ready to accept priority-setting, good leadership or a 'champion' for the priority-setting process and having a health economist to guide the process. Successful disinvestment was very uncommon in the experience of the researchers surveyed. Recommendations emerging from Program Budgeting and Marginal Analysis exercises appeared to be more widely implemented than those coming from alternative processes. Identifying if the process was repeated following the initial process was suggested as a means to measure success.

Effective but costly: How to tackle difficult trade-offs in evaluating health improving technologies in liver diseases

In the current context of rising health care costs and decreasing sustainability, it is becoming increasingly common to resort to decision analytical modeling and health economics evaluations. Decision analytic models are analytical tools that help decision makers to select the best choice between alternative health care interventions, taking into consideration the complexity of the disease, the socioeconomic context, and the relevant differences in outcomes. We present a brief overview of the use of decision analytical models in health economic evaluations and their applications in the area of liver diseases. The aim is to provide the reader with the basic elements to evaluate health economic analysis reports and to discuss some limitations of the current approaches, as highlighted by the case of the therapy of chronic hepatitis C. To serve its purpose, health economics evaluations must be able to do justice to medical innovation and the market while protecting patients and society and promoting fair access to treatment and its economic sustainability.

CONCLUSION

New approaches and methods able to include variables such as prevalence of the disease, budget impact, and sustainability into the cost-effectiveness analysis are needed to reach this goal. (Hepatology 2016;64:1331-1342).

Formal priority setting in health care: the Swedish experience

Purpose

From the late 1980s and onwards health care in Sweden has come under increasing financial pressure, forcing policy makers to consider restrictions. The purpose of this paper is to review experiences and to establish lessons of formal priority setting in four Swedish regional health authorities during the period 2003-2012.

Design/methodology/approach

This paper draws on a variety of sources, and evidence is organised according to three broad aspects: design and implementation of models and processes, application of evidence and decision analysis tools and decision making and implementation of decisions.

Findings

The processes accounted for here have resulted in useful experiences concerning technical arrangements as well as political and public strategies. All four sites used a particular model for priority setting that combined top-down- and bottom-up-driven elements. Although the process was authorised from the top it was clearly bottom-up driven and the template followed a professional rationale. New meeting grounds were introduced between politicians and clinical leaders. Overall a limited group of stakeholders were involved. By defusing political conflicts the likelihood that clinical leaders would regard this undertaking as important increased.

Originality/value

One tendency today is to unburden regional authorities of the hard decisions by introducing arrangements at national level. This study suggests that regional health authorities, in spite of being politically governed organisations, have the potential to execute a formal priority-setting process. Still, to make priority-setting processes more robust to internal as well as external threat remains a challenge.

An evaluation tool for assessing performance in priority setting and resource allocation: multi-site application to identify strengths and weaknesses

Introduction

An evaluation tool should help improve formal priority setting and resource allocation (PSRA) processes in Canada and elsewhere. These are crucial to maximizing value from limited resources.

Methods

On the basis of case studies, balanced scorecard development protocols and use-focused evaluation principles, an evaluation tool was developed based on an existing framework for high PSRA performance and implemented in two health care organizations in British Columbia, Canada.

Results

Implementation of the tool identified areas of strength, improvement and weakness in the pilot organizations’ processes for PSRA including: communication, staff engagement and culture. Refinements were identified and incorporated into the tool for future application.

Conclusion

This is the first documented multi-site application of such an evaluation tool. Broader dissemination should have use both in further refining the basis of the tool and in catalysing improved performance of PSRA practice.

'It ain't what you do it's the way that you do it': lessons for health care from decommissioning of older people's services

Public sector organisations are facing one of the most difficult financial periods in history and local decision-makers are tasked with making tough rationing decisions. Withdrawing or limiting services is an emotive and complex task and something the National Health Service has always found difficult. Over time, local authorities have gained significant experience in the closure of care homes - an equally complex and controversial issue. Drawing on local knowledge and best practice examples, this article highlights lessons and themes identified by those decommissioning care home services. We believe that such lessons are relevant to those making disinvestment decisions across public sector services, including health-care. The study employed semi-structured interviews with 12 Directors of Adult Social Services who had been highlighted nationally as having extensive experience of home closures. Interviews were conducted over a 2-week period in March 2011. Results from the study found that having local policy guidance that is perceived as fair and reasonable was advocated by those involved in home closures. Many local policies had evolved over time and had often been developed following experiences of home closures (both good and bad). Decisions to close care home services require a combination of strong leadership, clear strategic goals, a fair decision-making process, strong evidence of the need for change and good communication, alongside wider stakeholder engagement and support. The current financial challenge means that public sector organisations need to make tough choices on investment and disinvestment decisions. Any such decisions need to be influenced by what we know constitutes best practice. Sharing lessons and experiences within and between sectors could well inform and develop decision-making practices.

Multiple criteria decision analysis for health technology assessment

OBJECTIVES

Multicriteria decision analysis (MCDA) has been suggested by some researchers as a method to capture the benefits beyond quality adjusted life-years in a transparent and consistent manner. The objectives of this article were to analyze the possible application of MCDA approaches in health technology assessment and to describe their relative advantages and disadvantages.

METHODS

This article begins with an introduction to the most common types of MCDA models and a critical review of state-of-the-art methods for incorporating multiple criteria in health technology assessment. An overview of MCDA is provided and is compared against the current UK National Institute for Health and Clinical Excellence health technology appraisal process. A generic MCDA modeling approach is described, and the different MCDA modeling approaches are applied to a hypothetical case study.

RESULTS

A comparison of the different MCDA approaches is provided, and the generic issues that need consideration before the application of MCDA in health technology assessment are examined.

CONCLUSIONS

There are general practical issues that might arise from using an MCDA approach, and it is suggested that appropriate care be taken to ensure the success of MCDA techniques in the appraisal process.

Affordability as a discursive accomplishment in a changing National Health Service

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.

Must we ration health care for the elderly?

Resistance to rationing health care to the elderly is enormous. This article lays out the need for rationing, based on projections of Medicare expenditure in the near future, and the judgment of policy experts that there will be no technological breakthrough that might lower costs. Various forms of rationing possibilities are discussed as well as cultural and political obstacles to needed reform. Some general principles for thinking about health care for the elderly are presented.