The neglected fields of health care decision making - recent work at HSMC

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By Iestyn Williams

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Achieving a high quality and affordable health service has long been the holy grail for governments off all complexions and making wise decisions over where to put scarce financial resources is clearly very important in this.  In the past few decades, the drive for ‘evidence based’ policy decision making has changed much of the NHS landscape.  Most notably, national bodies such as the National Institute for Health and Care Excellence (England and Wales) and the Scottish Medicines Consortium have been producing guidance on the cost effectiveness of treatments for many years.  The principle tool used by these bodies is ‘Health Technology Assessment’ which involves aggregating the clinical and cost effectiveness evidence for a particular intervention, often through comparison with current practice.  At local levels, bodies such as medicines management and/or area prescribing committees also seek to apply best evidence to their decisions to adopt or reject new treatments.

The limitations of HTAs

However, HTA and bodies such as NICE only scratch the surface of health care decision making.  Not only do they cover only a small proportion of the clinical interventions for which decisions must be made, they are not designed or intended to inform other types of decisions such as: whether to invest in physical and technological infrastructure; to merge or disband organisations; or to revamp management and governance structures. These decisions have potentially huge implications for both budgets and outcomes in health, but the evidence to inform them is difficult to access, assemble and apply.  In recognition of this, recent research has addressed the challenge of measuring the economic costs and consequences of service change processes and decisions (e.g. Meacock 2018).

Exploring decision making further

Two recent projects carried out at HSMC explore these areas further.  The first is a literature review carried out for the NHS Confederation and the Academy of Medical Royal Colleges, and recently published in the International Journal of Health Policy and Management (Williams & Brown 2015; Williams et al. 2018). This analysis shows how such decisions are shaped by prevailing incentives, penalties and rewards as well as the dominant organisational culture and relationships.  It also suggests that the sheer volume of external oversight and regulation, not to mention legal opinion and precedent, can engender decision-making driven by compliance and risk aversion rather than a ‘rational’ calculation of likely outcomes.  Given these powerful contextual influences, an evidence-based mind-set is often at odds with a ‘practical-operational’ approach, in which contextual factors are accounted for (Dobrow et al. 2004).

A second study is currently being carried out for the Health Foundation, focussing on how constrained budgets for capital investment – for example in physical infrastructure, information technology and equipment – affect health care organisations and the services they provide.  Capital spending is again often neglected in the vast literature on priority setting, much of which focusses on decisions to invest (or disinvest) in treatments and services. Outputs from this project will soon be ready to share. 

Overall, it is clear from this emerging field of research that the somewhat narrow obsession with new health care interventions needs to be revisited.  As Scotland and Bryan (2017) argue, this means understanding the full range of inefficiencies in the system and, as we would argue at HSMC, focussing on the neglected fields of health care decision making.

For more information on these areas of work contact Iestyn Williams.