Resource Allocation and Priority Setting in Health Care: A Multi‐criteria Decision Analysis Problem of Value?

Abstract

A methodological approach is needed for allocating health care resources in an efficient and fair way that gives legitimacy to decisions. Currently, most priority setting approaches tend to focus on single or limited benefit dimensions, even though the value of new health care interventions is multi-dimensional. Explicit elicitation of social value trade-offs is usually not possible and decision-makers often adopt intuitive or heuristic modes for simplification purposes as part of an ad hoc decision-making process which might diminish the reasonableness and credibility of the decisions. In this paper, we suggest that multi-criteria decision analysis could provide a more comprehensive and transparent approach in health care to systematically capture decision-makers' concerns, compare value trade-offs and elicit their value preferences. We conclude that such methods could inform the development of a decision support system in health care, contributing towards more efficient, rational and legitimate resource allocation decisions. BackgroundOne of the foremost challenges health care systems are facing is the scarcity of resources in combination with rising demand for services, putting their sustainability in danger. As a result, decisions relating to the allocation of health care resources have been inevitable, either between different competing services and interventions (i.e. priority setting) or across different patients (i.e. rationing). However, the methodological approach of allocating resources in an efficient and fair way that gives legitimacy to decisions has been far from obvious (Beauchamp 2003;Eddy 1991aEddy , 1991bEmanuel 2000;Fleck 2001; Rawls,1999). This is in large part due to: (1) the complexity of the decisions, as a variety of different factors and objectives need to be balanced through the involvement of a range of stakeholders; (2) the importance of the decision outcomes, as they have a dramatic impact on human health; and (3) the ethical and social responsibilities behind the provision of health care which traditionally has been perceived as a government duty, given that health is often regarded as a public good or even a human right. Resource allocation methods in the British National Health ServiceThe British National Health Service (NHS) provides an insightful case study of how priority setting in health care evolved through the interplay of scientific advancements, culture changes and politics. As a result, priority setting today takes place across all levels of the organisational hierarchy of the British health care system: the central government sets the overall budget of the NHS, commissioners and providers determine their purchases among alternative services and interventions, and clinicians allocate their time and resources (Klein and Maybin, 2012). Already by 1993 in the UK, 'micro-decisions about priority setting [were] constrained by macro-decisions about resource allocation taken at superior levels in the organisational hierarchy' (Klein, 1993, p. 309), in an almost identi...

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“…19 - 22 A recent narrative review by Angelis et al identified several different priority systems for broader health service resource allocation decision-making. 23 Mapping these against the principles identified in this study illustrate that the findings are broadly consistent with pervious literature although there are additional factors that were not identified in the present study. For example, in the Netherlands, in 1990, the Committee on Choices in Health Care endorsed a set of four priority principles: necessity, effectiveness, efficiency and individual responsibility.…”

“…Individual responsibility was not identified as factor in the present study and was based on if it was acceptable for the individual to pay for services themselves. 23 …”

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“…Stated preferences are generally in line with the principles of resource allocation in healthcare: resources should be allocated where the largest total improvement is expected, that is, more people are affected, the quantity of life lived significantly increases, and the quality of life substantially improves. The total improvement is typically measured by the quality adjusted life year covering both the quality and the quantity of life lived; it is a widely used measure to assess the value for money of various interventions in healthcare, including funding (Angelis, Kanavos & Montibeller, 2017;Brazier, Deverill & Gree, 1999;Wouters, Naci & Samani, 2015).…”

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“…Broadly, priority setting in health care can be understood as any mechanism, formal or informal, which deliberates between the possible uses of available resources. Priority setting takes place from the bed-side-level to decisions at the national level [2,36,47,55,67,73,83,93,124].…”