Background
Due to limited resources, health care decision makers must make choices about what services to fund and what not to fund. This process of priority setting has traditionally been shaped by organizational cultures where norms and incentives have implicitly supported historically-based resource allocation processes [
1]. That is, in most health care organizations, the process underlying decision making is based on the previous year's expenditure being rolled over to the current year, with some political and/or demographic adjustments. This can lead to 'allocation by stealth' and enables politics to directly enter into the fray [
2]. The problem is, over the last decade, decision makers in various organizations across countries have expressed dissatisfaction with these processes, desiring more explicit, evidence based approaches to priority setting [
3‐
6].
In order to move away from historical and/or politically driven allocation models, towards a more explicit, evidence-based process, knowledge of the organizational context is required [
7,
8]. The reason for this is two-fold. First, sustainability of a novel process is reliant on that process fitting with existing practices and beliefs. Second, understanding the context provides insight into whether a move towards an explicit priority setting process is appropriate or desired by a given set of decision makers. Knowledge about current decision making practices within health care organizations is thus pivotal to improving priority setting processes [
2,
7].
To better understand organizational context with respect to priority setting and to investigate the possibility of moving towards a more explicit process, a survey of key decision makers was conducted in the Provincial Health Services Authority (PHSA) of British Columbia, Canada. The objectives of this survey were: 1) to obtain insight into past organizational practices with respect to priority setting; 2) to identify strengths and weaknesses of past priority setting activity; 3) to determine strategies for improvement in priority setting practices; and finally 4) to determine likely barriers and facilitators in, and ultimate feasibility for, moving towards an explicit process for priority setting.
The purpose of this paper is to present key findings of this decision maker survey. The findings serve to expand our understanding of the organizational context within the PHSA, and through this, should provide insight into how other organizations function with respect to priority setting and resource allocation processes. This work builds on previous surveys that have been conducted elsewhere in Canada and in Australia [
5,
6], and parallels ongoing research with health service commissioning bodies in the United Kingdom.
Results
The results are presented as follows: 1) current organizational practices; 2) strengths and weaknesses of priority setting activity to date; 3) strategies for improvement, particularly in relation to cultural change, stakeholder involvement, and fairness of process; and 4) barriers and facilitators in moving forward with an explicit approach to priority setting. The data presented reflects the opinions of key decision makers regarding priority setting at the macro-level of the PHSA. While data was also collected on the priority setting processes of the B.C. Children's Hospital and B.C. Mental Health services alone, these results are not presented here. The survey was designed to examine previous priority setting practices from the time the organization was constituted up to the time of the interviews (late 2002 – summer 2004).
Current priority setting processes
The priority setting process occurs at the level of the Executive Committee in the PHSA. Decision makers within the Executive Committee indicated that the process of priority setting is largely based on 'the squeaky wheel getting the grease', and suggested that resources tend to go to 'whoever yells the loudest'. This is exemplified by the opinion of this decision-maker:
It's a squeaky wheel process. Whoever is able to more clearly articulate their problem, or lobby for their group or, through some other form of power and influence, impact whatever process is in place that year will come out with some outcome.
Priorities were described as being set in an ad hoc manner, with resources allocated to satisfy the most people and incur the least opposition. The decision makers noted that priority setting usually occurs in the context of the budget cycle and that the process is driven by historical allocation. One decision maker described the process as follows:
I don't think that I'm really aware of any mechanism to determine medium and long-term priorities for the PHSA. I think that it is possibly because of the newness of the organization and, in essence, the imperative for its creation, which clearly prioritized balanced budgeting and sustainability as being the key drivers of the short-term. So I think when it comes to things such as priority setting and allocation, it's really been determined more by managing activity to budget than it has been in terms of strategic outcomes in terms of health care.
Decision makers stated that there had been little discussion of resource re-allocation across PHSA agencies, with each agency by and large operating as its own entity. Decision making criteria had been used in the past to assess alternative investment proposals in some instances, but the criteria were not consistent throughout the PHSA. However, decision makers would routinely incorporate best practice information when assessing options. Overall, it was clear that decision-makers were dissatisfied with current priority setting processes and desire a better framework by which to make decisions. One decision-maker phrased it in this manner:
No, I don't think [the system] works well. I think it works as well as it can without some more overarching framework in which to make those decisions... When you get down to it, if the decisions are, 'Should we put more into cancer or should we put more into mental health?' – who at the end of the day should actually be making that decision? As medical people, one can bring forward the evidence for the benefit. In terms of the costing, etc., one can bring the cost-effectiveness. But who actually is the beneficiary to set the priority?
Strengths and weaknesses
Decision makers identified a number of strengths in their priority setting practices. First, many respondents identified the creation of the Strategic Plan as a potential organizational strength. The year-long planning process incorporated both internal (i.e. employees) and external (i.e. other health authorities and the Ministry of Health) stakeholders and allowed them to come together to discuss the future directions of the PHSA. The aim of the strategic planning exercise was to establish a unified vision across the agencies. Decision makers viewed the plan as the first step towards a more "fair, open, and transparent" process. In theory, the goals outlined in the Strategic Plan were to created "to provide governance and direction to its agencies in order to achieve greater levels of efficiency and effectiveness through the consolidation of corporate services and to begin developmental work in coordinating province-wide services" [
16]. The Strategic Plan was officially released in April 2004, only several months before this study was conducted.
Another strength identified by decision makers was the openness of the PHSA towards explicit priority setting. One decision maker expressed that, "despite the whining and the gnashing of teeth, I think we're ready to move to something that makes a little more sense". In addition, the strong research base of the organization is a strength that was noted, with a clear appreciation for evidence in both policy-making and clinical practice. One decision-maker stated, "I think the fact that we have such a strong basic and translational research infrastructure within many of our health care organizations within the PHSA is a real strength".
Several weaknesses were also identified through the interviews and are summarized in Table
2. Weaknesses categorized as 'systemic' refer to issues in the structure, policy, or systems of the organization, while those categorized as 'individual' refer to the attitudes and behaviour of individual decision makers. The categories of internal and external weaknesses refer to issues within and outside of the PHSA, respectively.
Table 2
Perceived weaknesses in priority setting in the PHSA
| Central decision making creating a feeling of disempowerment among managers |
| Lack of true accountability to conserve resources |
| "Do it all" mentality that prevents the organization from identifying disinvestments |
| Incentive to overspend because efficiency is not rewarded |
| Lack of structural and cultural integration due to the recent creation of the PHSA |
|
External
|
| Confusion regarding role and authority of the BC Ministry of Health and the PHSA |
| Limitations in priority setting due to provincial mandate and global priority setting |
Individual
| Lack of priority setting skills and tools which support resource re-allocation |
| Unwillingness to release resources from own budgets to fund investments elsewhere |
| Fear of being explicit in priority setting |
| Decision makers jaded to change processes because of too much change in the institution |
| Lack of management training for physician-leaders |
One systemic, internal weakness was a lack of structural and cultural integration within the organization. This was attributed to the recent creation of the PHSA, and related to the challenge noted above of re-allocating resources across the agencies. In addition, decision makers said that there tended to be an organizational 'do-it-all' mentality, rather then an acceptance of needing to make overt rationing decisions. Another weakness noted by participants was a perceived lack of authority over program areas within the agencies. One decision maker preferred a structure where "individuals have a degree of autonomy and authority over their area of responsibility and have some flexibility within that area to move forward, rather than having to do everything at the most senior level".
A perceived weakness under the individual category was that decision makers would be unwilling to release resources from their own program budgets to fund investments elsewhere. As one decision maker described, "everybody thinks their business on this site is the most important, that it has to be done here. It's pretty hard to set priorities when everybody thinks their thing is the most important". Yet another weakness identified by many participants was a jaded attitude of decision makers towards new change processes. In response to the question of how decision makers would respond to explicit priority setting, one participant noted:
"I think people would be very jaded, to start with. It would need to be clear that people [are] just so fed up... So I think [an explicit process] would have to be very clear and would have to stand the test... It would have to show that there was open input and that people were able to make a difference."
Strategies for improvement
Decisions makers identified several improvement strategies that would overcome the weaknesses in their priority setting process. The main area for improvement, noted by the participants, was a desire to have a process that was more transparent and defensible (Table
3). Decision makers suggested that such a process should take both context and politics into consideration. In addition, a vision for the process should be defined and clearly communicated to all stakeholders. Participants also suggested that goals, outcomes, and benchmarks for success should be defined, using the PHSA Strategic Plan as a guide. The consistent application of the process was also seen as integral to any plan. In addition, it was felt that any process should be time-sensitive and driven by evidence. As one decision-maker noted, there is a strong research base of the organization, but the use of this evidence could be improved.
Table 3
Strategies for improvement
Increase transparency and accountability
| • Make the decision making process more transparent and accountable to internal and external stakeholders |
Create explicit process
| • Align process with organizational context and account for politics |
| • Clearly communicate vision of the process to all stakeholders |
| • Define goals, outcomes, and benchmarks for success incorporating the Strategic Plan |
Initiate cultural change
| • Create time-sensitive, evidence-driven process |
| • Apply the process in a consistent manner |
| • Provide education to create a culture of explicit priority setting |
Increase stakeholder involvement
| • Include public opinion at a general level and provide management training for physicians |
Enhance fairness
| • Create explicit appeals process for priority setting decisions |
We have a strong base of research in all of our organizations [agencies], so there is probably more evidence out there about what works and what doesn't work than we currently use in our resource allocation practices."
Decision makers further stated a need for developing a culture that supports explicit priority setting. It was suggested that this could be achieved through education of internal stakeholders and the demonstration of real results. The former was viewed as a key component to increasing awareness about explicit priority setting, while the ability to demonstrate results was seen as a way to positively reinforce the benefit of a new process and contribute to its continued use.
While the PHSA currently uses stakeholder opinion in priority setting, decision makers believed that stakeholder involvement could be improved. Participants stated that the general public was not involved in priority setting to date. The main reason cited for this was the difficulty of finding the right forum to garner public opinion. One decision maker described this predicament:
The public can be important, unquestionably, because that's really the only way one can put social context around how taxpayers' dollars get spent. So I don't have any difficulty with that context. How you engage the public and what you ask the public becomes a very difficult issue for consideration, because one can't really hold a Town Hall Meeting and say, "Where would you like your money spent – on mental health or cancer?"
Decision makers believed that while it was important to obtain public opinion, the ideal role of the public would be involvement at a fairly general level. For example, it was felt that ascertaining the public's opinion on broad areas of importance would be more useful than input on specific decisions. Participants suggested that this could be done through surveys, public forums, focus groups, or having a member of the public at the decision making table. One decision maker described what they viewed as the ideal role for the public:
I think the public would have to be involved at a very high level in deciding what the general goals and values are that one makes a decision around. They need to say "this is what is important for them" and then leave it to decision makers to apply those values to their decision making process and its up to the board be the governors to ensure that decision makers are applying that on their behalf.
In addition to the role of the public, participants were also asked about the role of physicians in priority setting. Many decision makers believed that physician-stakeholders were quite involved in priority setting already, but that their involvement could be improved. The majority of decision makers felt that the ideal role of physicians would be to bring clinical evidence to the table. Participants also noted that physicians face an inherent conflict of interest. With a fee-for-service system, physicians have an incentive to utilize services rather than conserve resources. This incentive can create difficulties in allocating system resources in the most efficient manner. It was suggested that physician training in management practice would be useful.
Another area of improvement cited by decision makers was the issue of fairness in priority setting. In the PHSA, participants noted that most decisions were publicly announced, but the rationale and decision making process behind the decisions were not publicly available. Despite this, participants believed that as a whole decisions were data-driven. Many decision makers also noted that there was no formal mechanism for appealing allocation decisions. As a result, decision makers did not believe that adequate enforcement existed to ensure that decisions were made in a fair and equitable manner. Overall, decision makers believed that components of the priority setting process could be considered fair, but that further improvement was required.
Barriers and facilitators for change
Despite the desire for greater transparency, decision makers identified a number of barriers that would hinder a move towards an explicit process based on the notion of re-allocating resources across service areas. One barrier was the mandate of providing specialized services. The PHSA is comprised of eight highly specialized agencies, which serve widely differing populations. With this mandate, decision makers must set priorities knowing that they are the only organization providing that service. Decision makers stated that setting priorities in this context can be quite difficult and that they do not feel they have the right tools to inform such decisions.
If you were to take something away from a place... it's not as though you could say, 'Okay, we're not going to do this at [Hospital A], but they can go to [Hospital B].' For the tertiary stuff that we do here, you can't do that, because there's no place else in the province. It's not as though we could say, 'Okay, we're not going to do that here, but somebody else will do it.' That, I think, is a significant barrier.
Other barriers identified in moving to an explicit priority setting process were a lack of shared vision in the PHSA, a lack of priority setting skills among the management team, and the lack of decision maker buy-in for such a move. In addition, decision makers noted that there was a lack of real or perceived authority to change the process and a significant political influence in priority setting. According to one decision-maker:
What tends to happen, I think, is that new programs get funded on the basis of politics, not on the basis of need or priority setting. So these last two or three years there's been money for autism – nothing to do with us; everything to do with politics. Five years before that it was eating disorders. Again, the politicians became involved and said, 'We must have an eating disorder program.' They didn't come to us and ask us what we wanted. They get very much involved in the micro-management and allocation process.
In addition, a lack of budget integration across agencies is a major barrier to explicit priority setting. On this issue, one decision maker stated that the PHSA has taken "a whole bunch of agencies and put them together, and all their budgets together with them." Participants commented that with the barriers of an historical structure, it is difficult to shift resources across agency lines.
To counterbalance the barriers for change, decision makers also highlighted several facilitators that would need to be fostered to aid in the implementation of an explicit priority setting process. These included a strong leadership team and commitment to explicit priority setting, as well as consistent application of the process, demonstrated results and an adequate amount of resources for re-allocation across services. One decision maker described the importance of strong leadership and commitment to priority setting:
I think fundamentally we have to have 100 percent commitment from the board and CEO. It's always the same. If they're not really committed to [it], then it's probably not going to be well endorsed.
In addition, a culture of openness to priority setting, a culture of learning, and a data-driven culture were cited as important facilitators that currently existed in the organization, which would assist in the implementation of an explicit priority setting process.
Competing interests
JM is a paid employee of the Provincial Health Services Authority of BC.
Authors' contributions
FT took the lead on drafting the paper. CM and JM made substantial intellectual contributions including input on study design, sample selection, questionnaire development and data analysis.