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Priority Setting Reduce Irrational Variation in Practices.12 EDITORIAL 1185 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.9.1185 on 21 August 2003. Downloaded from Priority setting reduce irrational variation in practices.12 ................................................................................... Although the best possible evidence is not available for all aspects of treatment, a recent text illustrates the usefulness of an Priority setting: learning to make evidence based approach to the clinical practice of neurology.13 tough decisions The above techniques place emphasis on such values as effectiveness and S R Benatar efficiency—both important social values, but not the only ones. Moreover, as they ................................................................................... are best applied at the level of comparing different treatments for the same disease The costs of trying to provide modern medical care for all who and it is more difficult to apply them to could potentially benefit exceed the capacity of most countries compare treatments of different dis- eases, judgement is also required. This riority setting (also termed resource the micro level of individual patient care. raises the thorny question of which allocation) for healthcare expendi- Medical practitioners are accustomed to values should be emphasised and whose ture is inevitable in all societies, making such decisions at the bedside or judgement should influence the estab- P 1 even the most affluent. New technol- the clinic and they value their autonomy lishment of priorities and the selection of ogies are the dominant driving forces.2 to do so. Advocates for implicit rationing a basket of essential services/treatments. Although these advances have been suc- see several disadvantages to explicit Increasingly efforts are being made to cessful both in saving lives and in (overt, reasoned, and accountable) ra- seek public opinion despite all the improving quality of life, the costs of try- tioning. They have doubts about the complexity this poses. An emphasis on ing to provide such modern medical care assumption that explicit rationing is judgement reveals the role of ethics and for all who could potentially benefit practical and possible, and believe that values. For example, judgement is re- exceed the capacity of most countries. explicitness will distress patients and quired to determine whether preference A very considerable proportion of providers. They are also troubled by the is given to improving the quality of life medical expenditure is generated on administrative complexity of the process, (for example palliative care) or to ex- treating patients during what turns out its potential to destabilise the healthcare tending the duration of life (for example to be the last year of life.3 It is now system, and the lack of responsiveness to through provision of more intensive care increasingly recognised that there are rapid changes in knowledge.78 beds). Similarly, a balance needs to be inadequate health returns from such Advocates of explicit rationing claim shaped between favouring the good of expenditure (both in terms of duration that equal need and equal access (NHS individuals and giving priority consid- and quality of life) and that there are principles), the unavoidable need for erations to the common good. copyright. limits to what medicine should be triage, and the ability to link triage to Central to priority setting is the ques- attempting to achieve.4 Consequently waiting lists, are good reasons to under- tion of justice. Ideas of what distributive there has been a subtle, but largely take rationing on an explicit basis. More- justice means and how it can be achieved unacknowledged, shift from a “sanctity over it is argued that the process reduces vary greatly.14 Some believe in individual of life” approach (in which medical care deception (and ignorance) and is less freedom as the most important political is continued relentlessly, even when paternalistic. Rationing is considered to value in the pursuit of fairness. Others death seems imminent) to “quality of be a requirement in a democracy as it are more concerned about equity, soli- life” considerations.5 This is reflected in encourages politicians and administra- darity, and contractual theories of justice the wishes of many patients to be spared tors to reflect on their decisions and, in that could contribute to achieving the ongoing heroic measures and to be the process, attain deeper insights into ideal of a harmonious public life. Per- allowed to die peacefully. Increasingly the implications of their decisions. It is spectives on justice also differ across dis- http://jnnp.bmj.com/ healthcare professionals are also willing also claimed that explicit rationing could ciplines. For example, philosophers are to withdraw treatment when the prog- contribute to the moral development of interested in complex and disparate nosis seems very poor, or when other citizens by encouraging them not to theories of distributive justice, while goals of health care are considered to be believe that they are entitled to every- lawyers concentrate on the right to higher priorities.6 thing that is technically possible in health care, non-discrimination, and the Additional reasons for interest in health care, especially when benefits are obligations of healthcare practitioners. priority setting, beyond the appropriate- only marginal.9 Political scientists reflect on the fairness ness of aggressive medical care, include The requirements for explicit rationing of decision making processes. Medical on September 26, 2021 by guest. Protected the need for more equitable access to include the use of techniques such as cost staff tend to be caught up with the care and the desirability of reducing effectiveness analysis, systematic reviews evidence base and considerations of best arbitrariness in medical practice through of outcomes, scoring systems such as clinical judgement, while economists use of practice guidelines informed by quality adjusted life years (QUALYs), as stress efficiency. the best evidence. well as clarity about objectives, infor- In the absence of a satisfactory theory As many values are at stake and there mation about costs and outcomes, and the of justice that can be applied in everyday are differing rankings given to these, the ability to measure performance. A re- practice, American scholars Daniels and debate about priority setting has been cently published cost effectiveness study Sabin have proposed a process for prior- heated and acrimonious. In the United of four disease modifying treatments for ity setting that they have called “ac- Kingdom, strong arguments have been relapsing and remitting multiple sclerosis countability for reasonableness”. This advanced to retain the traditional illustrates the complexity of such techni- framework requires that a fair priority method of implicit (or covert) rationing. cal processes10 and highlights the ongoing setting process meets four conditions. Advantages claimed for implicit ration- need to pursue such studies and accumu- Firstly, the rationale for decisions must ing are that it is based on trust, and that, late additional follow up data.11 The role of be publicly accessible. Secondly, the deci- because it is more sensitive to the randomised control trials in providing the sions to meeting healthcare needs must complexity of medical decisions as well best evidence on which to base practice be contextually relevant to fair minded as to the personal and cultural prefer- guidelines is gaining prominence as the people. Thirdly, allowance must be made ences of patients, it is the best method at best way to justify expenditure and to for appeals so that previous decisions can www.jnnp.com 1186 EDITORIAL J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.9.1185 on 21 August 2003. Downloaded from be reconsidered in the light of new countries, but some places for example countries.21 Although significant progress evidence or arguments. Fourthly, there The Netherlands, Sweden, New Zealand, is being made towards improving fairness must be a process of enforcement that the United Kingdom, and the state of in the use and distribution of health serv- facilitates the implementation of the last Oregon in the United States, have moved ices, much remains to be done. three conditions.15 to explicit rationing processes. While the J Neurol Neurosurg Psychiatry Priority setting needs to be addressed specific approaches in each of these 2003;74:1185–1186 at several levels with different implica- places differ, common themes include tions and even different approaches at the importance of well publicised indi- ..................... each level. At national levels the budget vidual cases in bringing priority setting Author’s affiliation for public health services is determined to public attention and the need to con- largely by the fiscal policy of S R Benatar, Department of Medicine, sult and involve the public to ensure that University of Cape Town, Observatory, 7925, governments—hopefully influenced in their views and values contribute to Cape, South Africa; democratic countries by the “will of the making judgements.19 [email protected] people” and the priority they give to It is doubtful whether more than a few health care. Within regional geographical people know how resources are allocated REFERENCES areas, allocation decisions are potentially at national, regional, or institutional lev- 1 Daniels N, Sabin JE. Setting limits fairly: can influenced by policies of both national
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