Budget pressures and the role of priority setting in the contemporary NHS

“The current tough financial context for the NHS was recognised, and depicted as the elephant in any room in which future health and care strategy is being discussed.”

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Financial pressures loomed large in the discussions this week as Simon Stevens addressed an audience at the University of Birmingham Distinguished Lecture series.  There was reflection on the causes of the recent squeeze on health care spending (‘when the UK economy sneezes, the NHS catches a cold’) and discussion about solutions: increased effectiveness and efficiency, integration within the health system and also with social care, and an £8 billion funding injection promised for the current Parliament.

To these medium term ambitions was added a commitment to much lauded but often thwarted long-term ambitions:

  1. the fostering and spread of healthy behaviours and
  2. programmes to tackle the social determinants of health and ill health. 

On the former, we were reminded of the risk of rising levels of obesity, not just to public health but also to the public purse, and also in exacerbating already unacceptable levels of health inequality across districts and regions.  Similarly, the impact of social determinants on health was emphasised, with Simon reflecting on the fact that the ward of Birmingham in which he grew up is now characterised by indicators of poor health and life expectancy when compared with leafier districts of the city. 

The current tough financial context for the NHS was recognised, and depicted as the elephant in any room in which future health and care strategy is being discussed. It was made clear that primary care, mental health and social care have borne the brunt of these pressures to date.  Improvements in these areas, allied to a refocussing of resources on areas of highest need and early intervention, were offered as the main strategies for reversing the apparently inexorable trend towards higher spending on health care.

Perhaps not surprisingly, the primary focus in the lecture was on the demand side of the equation, with the overall funding settlement and the spectre of rationing being less of a topic for discussion. Therefore although priorities were expressed - for example a clear commitment to public health, primary care and targeting areas of highest need – the discussion did not then turn to where corresponding limits and/or reductions in funding would be expected to fall. These are questions that go to the heart of what we seek to achieve through publicly funded health care: where should the balance be struck between promoting population health and caring for those who fall sick?  What sacrifices in overall services might be warranted in order that the needs of those with the worst health profiles are addressed? 

The term ‘priority setting’ refers to the attempt to make explicit decisions about what can and cannot be provided as part of publicly funded health coverage and provision. There are many possible approaches to setting priorities in health but typically these are united by the aim of making the reasoning behind resource allocation decisions clear to all, and to commitment to channelling limited funds to programmes deemed  most valuable (however value is understood).  To this end, and in a context of budget constraint, a discussion about the role that priority setting might play in tackling financial pressures is timely.

Of course, no right-thinking health care leader or politician will put themselves in the position of publicly listing the services they believe should be reduced, restricted or removed from national funding and Simon Stevens held fast to his assertion that we will continue to have a comprehensive publicly funded health service which does more rather than less – with the promise that better health outcomes will come about from reducing demand for health services in the future, as inequalities and public health concerns are addressed.  

This perhaps exemplifies the challenge for priority setting if it is to become a genuine tool for influencing health care decisions.  Notwithstanding the guidance produced by NICE and some local examples of good practice, priority setting has remained somewhat peripheral when it comes to the realities of budget allocation and service commissioning in health and care.  Explicit priorities have often proved easier to assert than to operationalise, and there remain powerful forces which can inhibit change both locally and nationally. Without the levers and the political support to actually enact the sometimes unpalatable aspects of priority setting, local bodies in particular often find themselves as the mercy of a hostile media and unsupported in addressing resistance from stakeholders.

Taken in combination, these factors give us pause for thought as to the prospects for priority setting as a means of addressing financial problems in health.  So what will it take for priority setting to make a difference in these circumstances?  In September 2016 the Health Services Management Centre and the Department for Health Economics are hosting the 11th Biennial meeting of the Society for Priorities in Heath at the University of Birmingham, and these themes will be high on the agenda for discussion. 

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