Moving forward on rationing: an economic view

Abstract

Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:), two ethicists (doi:), and four health economists discuss how their ideas have developed—and been put into practice—since then

Decision-Making Criteria among National Policymakers in Five Countries: A Discrete Choice Experiment Eliciting Relative Preferences for Equity and Efficiency

“…This work has coalesced into a subfield of health economics with preference research presenting the methods and feasibility for including equity, efficiency, and other criteria in decision making in a variety of countries and settings [1][2][3][11][12][13][14][15][16][17]. These experiences may show a substantial and important impact of these criteria on decision making based on effectiveness and efficiency [12].…”

“…Worldwide, there is a need for formalization of health priority setting processes at both the national and local levels [1][2][3][4][5]. Too often policy decisions are made without transparency of decisionmaking criteria, but with implicit trade-offs.…”

Commissioning NHS dentistry in England: Issues for decision-makers managing the new contract with finite resources

“…Adaptation of a PBMAbased framework for dentistry may be one way to guide decision-makers through the commissioning process whilst attempting to ensure that finite resources are managed efficiently and transparently. Inclusive decision-making frameworks may foster closer working relationships between PCOs, dentists and local populations [43] and may enhance understanding of the challenges faced by those charged with managing finite resources [25].…”

“…The marginal analysis (MA) phase includes a wide range of stakeholders and may include clinicians, patients, public health specialists and NHS managers in specially formed 'advisory panels' to inform the decision-making process about whether the current pattern of spending within the programme is optimal, and, if not, what changes can be made. Participants interpret the available evidence, agree local priorities and then identify programmes for investment or disinvestment based upon the key economic principles of opportunity cost (through choosing to invest more in one part of the programme benefits may be forgone through choosing not to fund an alternative) [25] and consideration of the margin (the consequences of changes in the scale of service provision) [26]. Thus, PBMA may be one approach through which to structure the local commissioning of NHS dental services whilst developing a rational basis to the management of scarce resources.…”

Rationing in the fiscal ice age

“…This involves scoring candidates for investment on 11 criteria -ranging from the magnitude of the benefit to impact on health inequality -using a five-point scale (see also Airoldi and Bevan, 2010). Other techniques are on offer and in use, notably Programme Budget and Marginal Analysis (PBMA), designed to create an economic framework within which account can be taken of equity and other criteria (Donaldson et al, 2008;Wilson et al, 2008). Different methodologies and different local contexts inevitably lead to different decisions being taken.…”