A politics of priority setting: Ideas, interests and institutions in healthcare resource allocation
| Date | 01 October 2014 |
| Author | Neale Smith,Alan Davidson,Craig Mitton,Iestyn Williams |
| Published date | 01 October 2014 |
| DOI | 10.1177/0952076714529141 |
| Subject Matter | Articles |
Public Policy and Administration
2014, Vol. 29(4) 331–347
!The Author(s) 2014
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DOI: 10.1177/0952076714529141
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Article
A politics of priority
setting: Ideas, interests
and institutions
in healthcare resource
allocation
Neale Smith
Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal
Health Research Institute, University of British Columbia, Canada;
Centre for Health Promotion Studies, School of Public Health,
University of Alberta, Canada
Craig Mitton
Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal
Health Research Institute, Canada; School of Population and
Public Health, University of British Columbia, Canada
Alan Davidson
Faculty of Health and Social Development, University of British
Columbia, Canada
Iestyn Williams
Health Services Management Centre, School of Social Policy,
University of Birmingham, UK
Abstract
Across a range of health care systems there is a responsibility placed on meso-level
budget holders to set priorities and allocate resources within constrained budgets. The
literature suggests that these organizations have typically defaulted to historical and/or
political processes for decision making. Whilst the literature on resource allocation in
health care attests to the political nature of decision making, this has remained largely
under-theorized and therefore priority setters may be unfamiliar with the analytic
benefits of applying insights from the broader political sciences. Conversely, policy sci-
entists may know relatively little about existing research on how healthcare
Corresponding author:
Neale Smith, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute,
University of British Columbia, 7th floor, 828 W 10 Ave, Vancouver, BC V5Z1M9, Canada.
Email: neale.smith@ubc.ca
organizations make allocative and redistributive decisions. This paper aims to open a
dialogue between these solitudes by exploring political effects on health care priority
setting, using the interpretive concepts ideas, interests and institutions.
Keywords
Priority setting, resource allocation, rationing, healthcare management, political science
Introduction
In health care, priority setting refers to ‘decisions about the allocation of resources
between the competing claims of different services, different patient groups or dif-
ferent elements of care’ (Klein, 2010: 389). Formal responsibility for these decisions
can be allocated to actors such as a national guidance producing agency (e.g. the
UK’s National Institute for Clinical and Health Excellence (NICE)) or left to occur
at the micro-level of patient–clinician interaction. Most commonly, however, there
is a meso- (or ‘middle’) tier of decision making and resource allocation which is
required to exercise some discretion and responsiveness to local population need
while adhering to higher political expectations and frameworks (such as Regional
Health Authorities (RHAs) in Canada or Clinical Commissioning Groups in the
UK). In this paper, we refer to this meso-tier as local level priority setters.
Despite variation in role and remit, these decision makers typically face limited
resources and potentially unlimited demand at every turn. Competition for the
healthcare dollar can be fierce. In response, health services researchers have been
quick to offer up formal decision-making frameworks or processes which they
promise will bring consistency, rigour and public defensibility to priority setting
– e.g. Multi-Criteria Decision Analysis (Baltussen and Niessen, 2006; Defechereux
et al., 2012), Program Budgeting and Marginal Analysis (PBMA) (Mitton and
Donaldson, 2001; Mitton et al., 2003; Peacock et al., 2010), and Accountability
for Reasonableness (Daniels and Sabin, 2002; Gibson et al., 2005), even combin-
ations of these (Gibson et al., 2006). These processes are meant to help in making
comparisons and trade-offs among spending options.
However, formal priority setting frameworks cannot deliver instant resolution
to the seemingly intractable allocation problem. Priority setting activities must
contend with on-going and relentless pressures from political, social, cultural and
economic forces, both internal and external. Research with decision makers in
(public) healthcare service delivery organizations in Canada (Dionne et al., 2008;
Gibson et al., 2005; Mitton et al., 2005), Australia (Astley and Wake-Dyster, 2001;
Mitton and Prout, 2004), New Zealand (Ashton et al., 2000; Bohmer et al., 2001),
the UK (Bate et al., 2007; Greener and Powell, 2003; Joyce, 2001; McCafferty et al.,
2012) – this is by no means an exhaustive list – has uncovered a range of contextual
or environmental factors that motivate various persons to advocate (or to oppose)
formal processes for priority setting, and which shape how successfully such efforts
are introduced into, carried out by and sustained in particular organizations.
332 Public Policy and Administration 29(4)
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