Priority setting at the micro level

Transcription

1 Priority setting at the micro level Decision-making in different contexts Amanda Owen-Smith, Joanna Coast, Jenny Donovan

2 Priority setting in the UK NHS Central Government Local budget holders Clinicians Media NICE Public Courts Patients

3 Priority setting in the UK NHS Central Government Local budget holders Clinicians Media NICE Public Courts Patients

4 Explicit healthcare rationing Central to dominant ethical frameworks Reflected in policy reforms (e.g. NICE) Empirical research Supported by citizens Supported by clinicians Supported by patients BUT clinicians face difficulties in practice

5 There's a 22 year old or something who tried to commit suicide because he was so obese, and he was getting teased and can't get a job. And I had to say well I'm really sorry but I can't offer you this operation, and I just come out from the end of the clinic feeling you know, in tears almost as well. I'm just having to write back now without seeing them in clinic because I just can't bear to have to make that decision. (Clinician)

6 Qualitative study design Two studies: 1) Prioritisation for morbid obesity surgery 2) Prioritisation for kidney transplant listing Data collection: 1) In-depth interviews with clinicians 2) Observations of consultation style Analysis through constant comparison

7 Qualitative study design Two studies: 1) Prioritisation for morbid obesity surgery 2) Prioritisation for kidney transplant listing Data collection: 1) In-depth interviews with clinicians 2) Observations of consultation style Analysis through constant comparison

8 Sample characteristics Interviews Observations Obesity surgery 8 referring clinicians 3 AHPs (all invited) 11 new consults 11 follow ups (purposive sampling) Transplant listing 8 referring clinicians 2 AHPs (purposive sampling) 62 follow ups (sequential sampling) Key constraint Funded surgery slots Number of organs

9 Managing resource constraints Most accept reality of rationing We re treating about 1/3 of 1% of the patients who could be eligible. (OC10) Conflict with individual patient advocacy You ve got a complete conflict of interest between your patients. (RC4) External prioritisation helpful Some of it s done for us, you know, by the allocation scheme. (RC1)

10 Key factors in decision-making 1. Clinical indicators and patient safety 2. Age and co-morbidity You have to have an outlook of ten years in order to realise most of the benefits. (OC6) 3. Behavioural factors You don t want to waste a kidney on someone who s just going to not look after it. (RC4) 4. Utilitarian concerns?

11 One of the main causes of transplant failure is the person dies with a functioning kidney and with small resources, ok, you ve got to think where s that kidney best placed, yeah. It s not best placed in a person who s gonna be dead in two years time. (RC4)

12 Explicitness in theory Nearly all clinicians wanted to be open I think you have to be frank with them and say look you know, that is what the rules are and there is no way of getting around it. (OC3) However they met barriers in practice I don t tend to talk about transplantation in someone who would clearly be untransplantable because I think that just raises unrealistic expectations that you would then go on to say actually no. (RC3)

13 Explicitness in practice 1 clinician in each group was usually explicit Alternative practices: Wait for the patient to ask

14 Pat: Dr: Pat: Dr: Pat: What are the alternatives if you get to that stage? So dialysis comes if you have kidney failure? Yeah, that s right. And, well I ll ask about transplant, because I don t know anything about it. What about transplant? Okay, so if you wanted to have a transplant, you d have to go and see a cardiologist to see if you re fit to have the operation getting a transplant from the list isn t impossible but the benefit of transplant in someone who is 72 is less than someone who is 35, because someone who is 35 has got more years to benefit. I understand that.

15 Explicitness in practice 1 clinician in each group was usually explicit Alternative practices: Wait for the patient to ask Talk about something else

16 Pat: And there was me nearly hoping you d say, but we ve got a cancellation, we can get you in this afternoon for this weight loss surgery Dr: (long pause) (writing) I ve put here [in patient notes] to continue the Glycoside [diabetes medication] Pat: Marvellous, yeah.

17 Explicitness in practice 1 clinician in each group was usually explicit Alternative practices: Wait for the patient to ask Talk about something else Rationing hand-offs

18 You can put somebody on the list and confidently expect they ll never get a kidney if you list a 65 year old for a completely HLA matched kidney from a 20 year old donor, which you could set criteria for, it s never gonna happen, not in a month of Sundays. (RC1)

19 Explicitness in practice 1 clinician in each group was usually explicit Alternative practices: Wait for the patient to ask Talk about something else Rationing hand-offs Give in!

20 Explicitness in practice 1 clinician in each group was usually explicit Alternative practices: Wait for the patient to ask Talk about something else Rationing hand-offs Give in! I have a patient myself who is now 73 who flatly refuses to come off the list. (RC8)

21 Key messages Resource constraints in both areas External prioritisation frameworks helpful Clinical & behavioural factors used to prioritise More discussion of utilitarian concerns in renal All meet barriers to explicitness in practice Doctor-patient relationships were key concern

22 Limitations and future work Different sampling strategies Extrapolation problematic Primary care decision-making excluded Future work Further analysis of consultations PC study of end of life care

23 Contact Details Dr Amanda Owen-Smith Social and Community Medicine University of Bristol Acknowledgments National Institute for Health Research NHS Bristol Taunton & Somerset NHS Foundation Trust