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Reckers-Droog V et al (2020) et al./Health Policy 124143–151

The paper’s bottom line, text from the paper chosen by 3VH


Our study showed that participants’ views partly remained stable over the course of the panel, specifically regarding equal access to healthcare, prioritisation based on patients’ needs, and the importance of the size and type of treatment benefits.  Notable changes after deliberation concerned the increased support for prioritisation, consideration of costs, and relevance of a cost-effectiveness criterion in allocation decisions.  Considering the increasing interest in deliberative methods among policy makers in healthcare and the limited and empirical evidence concerning the effect of deliberative methods on participants’ views and preferences, further research is required to better understand how deliberative methods can contribute to the legitimacy of and public support for the outcomes of allocation decisions in healthcare.

3VH commentary on the Implications for value improvement

Every country committed to universal health coverage allocates responsibility to local jurisdictions, a jurisdiction being a politically determined geographical area.  The precise nature of the responsibility delegated varies from country to country.  In countries in which healthcare is largely tax based the whole budget will be delegated, having top sliced resources for activities which are best done nationally.  In countries with insurance based healthcare the role of the local delegated authority varies.  They may be expected to monitor what is happening and of course in most tax based and insurance based countries social care is usually provided by local government outside the health service, so close cooperation is needed because of the impact of healthcare on social care and vice versa.

Having allocated resources to a defined population, decisions then have to be made about the allocation of resources to different segments of the population, to people with mental health problems or to people with cancer for example  but how are these decisions best made?

The answer is that no-one knows and there is no simple formula that can be used .. the most important principle seems to the concept of accountability for reasonableness Accountability for reasonableness is the idea that the reasons or rationales for important limit-setting decisions should be publicly available. In addition, these reasons must be ones that ‘fair-minded’ people can agree are relevant to pursuing appropriate patient care under necessary resource constraints). This is our central thesis, and it needs some explanation.

“By ‘fair-minded’, we do not simply mean our friends or people who just happen to agree with us. We mean people who in principle seek to cooperate with others on terms they can justify to each other. Indeed, fair-minded people accept rules of the game – or sometimes seek rule changesthat promote the game’s essential skills and the excitement their use produces.”

Source: Daniels, N. and Sabin, J.E. (2008) Setting Limits Fairly, Learning to Share Resources for Health. Oxford University Press. (p.44).

This means that the people who are given the responsibility for allocation need training and the opportunity to reflect on their own prejudices. This week’s paper report the results of an attempt to do this but the focus is on the rational, objective elements of decision making rather than on understanding the subjective, emotional factors that come to play when engaged in this very task, which in the end is based on judgement, influenced by the personal values of the decision makers as well as data on cost effectiveness.

Decision makers need to be given time for reflection on their own particular experience and views and how they maybe biased, fir the best of reasons. They do need to understand techniques such as cost benefit analysis but they also need to be aware of the fact that they and their fellow decision makers may be be bringing unreasonable attitudes  to the board table without any opportunity to surface or discuss them, for example attitudes shaped by personal experience or a particular concern for people with rare diseases but these all need to be made open and shared to prevent unreasonable decision making.