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Collins M, Mazzei M, Baker R, Morton A, Frith L, Syrett K, Leak P, Donaldson C. Developing a combined framework for priority setting in integrated health and social care systems. BMC Health Serv Res 2023; 23:879. [PMID: 37605123 PMCID: PMC10440867 DOI: 10.1186/s12913-023-09866-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND There is an international move towards greater integration of health and social care to cope with the increasing demand on services.. In Scotland, legislation was passed in 2014 to integrate adult health and social care services resulting in the formation of 31 Health and Social Care Partnerships (HSCPs). Greater integration does not eliminate resource scarcity and the requirement to make (resource) allocation decisions to meet the needs of local populations. There are different perspectives on how to facilitate and improve priority setting in health and social care organisations with limited resources, but structured processes at the local level are still not widely implemented. This paper reports on work with new HSCPs in Scotland to develop a combined multi-disciplinary priority setting and resource allocation framework. METHODS To develop the combined framework, a scoping review of the literature was conducted to determine the key principles and approaches to priority setting from economics, decision-analysis, ethics and law, and attempts to combine such approaches. Co-production of the combined framework involved a multi-disciplinary workshop including local, and national-level stakeholders and academics to discuss and gather their views. RESULTS The key findings from the literature review and the stakeholder workshop were taken to produce a final combined framework for priority setting and resource allocation. This is underpinned by principles from economics (opportunity cost), decision science (good decisions), ethics (justice) and law (fair procedures). It outlines key stages in the priority setting process, including: framing the question, looking at current use of resources, defining options and criteria, evaluating options and criteria, and reviewing each stage. Each of these has further sub-stages and includes a focus on how the combined framework interacts with the consultation and involvement of patients, public and the wider staff. CONCLUSIONS The integration agenda for health and social care is an opportunity to develop and implement a combined framework for setting priorities and allocating resources fairly to meet the needs of the population. A key aim of both integration and the combined framework is to facilitate the shifting of resources from acute services to the community.
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Affiliation(s)
- Marissa Collins
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK.
| | - Micaela Mazzei
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Alec Morton
- Department of Management Science, University of Strathclyde, Glasgow, UK
| | - Lucy Frith
- Centre for Social Ethics & Policy, University of Manchester, Manchester, UK
| | - Keith Syrett
- University of Bristol Law School, University of Bristol, Bristol, UK
| | - Paul Leak
- Directorate of Health and Social Care, Scottish Government, Edinburgh, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
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Hasson H, Nilsen P, Augustsson H, Ingvarsson S, Korlén S, von Thiele Schwarz U. To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol. Implement Sci 2019; 14:70. [PMID: 31286964 PMCID: PMC6615200 DOI: 10.1186/s13012-019-0919-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/27/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations. METHODS Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance. DISCUSSION This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.
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Affiliation(s)
- Henna Hasson
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden. .,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm County Council, SE 171 29, Stockholm, Sweden.
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden
| | - Hanna Augustsson
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm County Council, SE 171 29, Stockholm, Sweden
| | - Sara Ingvarsson
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden
| | - Sara Korlén
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
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Harris C, Green S, Ramsey W, Allen K, King R. Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting. BMC Health Serv Res 2017; 17:633. [PMID: 28886735 PMCID: PMC5591535 DOI: 10.1186/s12913-017-2507-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective. DISCUSSION Four themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment. There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term 'disinvestment' should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches. The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed. A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon. The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers. There is little evidence of successful implementation of 'disinvestment' projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs. CONCLUSIONS These findings suggest that the construct of 'disinvestment' may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Clinical Effectiveness, Monash Health, Melbourne, Australia
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Melbourne, Australia
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Clinical Effectiveness, Monash Health, Melbourne, Australia
| | - Richard King
- Medicine Program, Monash Health, Melbourne, Australia
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How have systematic priority setting approaches influenced policy making? A synthesis of the current literature. Health Policy 2017; 121:937-946. [PMID: 28734682 DOI: 10.1016/j.healthpol.2017.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022]
Abstract
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.
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Harris C, Allen K, King R, Ramsey W, Kelly C, Thiagarajan M. Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting. BMC Health Serv Res 2017; 17:328. [PMID: 28476159 PMCID: PMC5420107 DOI: 10.1186/s12913-017-2211-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background This is the second in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Rising healthcare costs, continuing advances in health technologies and recognition of ineffective practices and systematic waste are driving disinvestment of health technologies and clinical practices that offer little or no benefit in order to maximise outcomes from existing resources. However there is little information to guide regional health services or individual facilities in how they might approach disinvestment locally. This paper outlines the investigation of potential settings and methods for decision-making about disinvestment in the context of an Australian health service. Methods Methods include a literature review on the concepts and terminology relating to disinvestment, a survey of national and international researchers, and interviews and workshops with local informants. A conceptual framework was drafted and refined with stakeholder feedback. Results There is a lack of common terminology regarding definitions and concepts related to disinvestment and no guidance for an organisation-wide systematic approach to disinvestment in a local healthcare service. A summary of issues from the literature and respondents highlight the lack of theoretical knowledge and practical experience and provide a guide to the information required to develop future models or methods for disinvestment in the local context. A conceptual framework was developed. Three mechanisms that provide opportunities to introduce disinvestment decisions into health service systems and processes were identified. Presented in order of complexity, time to achieve outcomes and resources required they include 1) Explicit consideration of potential disinvestment in routine decision-making, 2) Proactive decision-making about disinvestment driven by available evidence from published research and local data, and 3) Specific exercises in priority setting and system redesign. Conclusion This framework identifies potential opportunities to initiate disinvestment activities in a systematic integrated approach that can be applied across a whole organisation using transparent, evidence-based methods. Incorporating considerations for disinvestment into existing decision-making systems and processes might be achieved quickly with minimal cost; however establishment of new systems requires research into appropriate methods and provision of appropriate skills and resources to deliver them. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2211-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Victoria, Australia.
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia.,Centre for Clinical Effectiveness, Monash Health, Victoria, Australia
| | - Richard King
- Medicine Program, Monash Health, Victoria, Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Victoria, Australia
| | - Cate Kelly
- Medical Services, Melbourne Health, Victoria, Australia
| | - Malar Thiagarajan
- Ageing and Aged Care Branch, Department of Health and Human Services, Victoria, Australia
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Smith N, Mitton C, Dowling L, Hiltz MA, Campbell M, Gujar SA. Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory. Int J Health Policy Manag 2015; 5:23-31. [PMID: 26673646 DOI: 10.15171/ijhpm.2015.169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/14/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA) processes at a Canadian healthcare institution reached the decision agenda of the organization's senior leadership. We adopt key concepts from an established policy studies framework - Kingdon's multiple streams theory - to inform our analysis. METHODS Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process - Program Budgeting and Marginal Analysis (PBMA) - in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon's model as a template. RESULTS The introduction of PBMA can be understood as the opening of a policy window. A problem stream - defined as lack of broad engagement and information sharing across service lines in past practice - converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes. CONCLUSION Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Mary-Ann Hiltz
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Matthew Campbell
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Shashi Ashok Gujar
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada.,Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Cromwell I, Peacock SJ, Mitton C. 'Real-world' health care priority setting using explicit decision criteria: a systematic review of the literature. BMC Health Serv Res 2015; 15:164. [PMID: 25927636 PMCID: PMC4433097 DOI: 10.1186/s12913-015-0814-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/23/2015] [Indexed: 11/24/2022] Open
Abstract
Background Health care decision making requires making resource allocation decisions among programs, services, and technologies that all compete for a finite resource pool. Methods of priority setting that use explicitly defined criteria can aid health care decision makers in arriving at funding decisions in a transparent and systematic way. The purpose of this paper is to review the published literature and examine the use of criteria-based methods in ‘real-world’ health care allocation decisions. Methods A systematic review of the published literature was conducted to find examples of ‘real-world’ priority setting exercises that used explicit criteria to guide decision-making. Results We found thirty-three examples in the peer-reviewed and grey literature, using a variety of methods and criteria. Program effectiveness, equity, affordability, cost-effectiveness, and the number of beneficiaries emerged as the most frequently-used decision criteria. The relative importance of criteria in the ‘real-world’ trials differed from the frequency in preference elicitation exercises. Neither the decision-making method used, nor the relative economic strength of the country in which the exercise took place, appeared to have a strong effect on the type of criteria chosen. Conclusions Health care decisions are made based on criteria related both to the health need of the population and the organizational context of the decision. Following issues related to effectiveness and affordability, ethical issues such as equity and accessibility are commonly identified as important criteria in health care resource allocation decisions. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0814-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ian Cromwell
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, Vancouver, Canada. .,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada.
| | - Stuart J Peacock
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, Vancouver, Canada. .,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada. .,School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada. .,Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, Canada.
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