Editorial - Vol 4, No 5:  Prioritising Health Services

This month’s edition of Healthcare Review – Online^TM considers the important issue of prioritisation in health care.

Making decisions about who does, or does not, receive health care services has been a feature of health care systems for decades. Recent initiatives aimed at making these decision-making processes more explicit have been the subject of wide debate.

The concept of ’rationing’ can produce quite an emotional response. But the concept of a health service that can totally avoid rationing through increased investment is becoming a very distant reality, as was made clear by England’s health secretary earlier this year. At a debate organised by the Institute for Public Policy Research in London, Alan Milburn said: "The NHS (National Health Service) – just like every other health system in the world, public or private – has never, or will never, provide all the care it might theoretically be possible to provide. That would probably be true even if the whole of the UK gross domestic product was spent on health care. So within our expanding health system there will always be choices to be made about the care to be provided." ¹

While rationing is becoming a reality, the concept of prioritisation is perhaps better accepted than that of rationing. The need to prioritise, even if considerably more money were invested in health care services, is recognised.

In this edition we use the example of the management of communicable disease to illustrate the principles used in prioritisation of health care services.

The paper provided by Dr Valerie Orchard, Science & Research Manager, Dr Michael Baker, Public Health Physician, and Dr Diana Martin, Principal Scientist, Communicable Disease Group, ESR, Kenepuru Science Centre, Porirua, New Zealand, provides a thorough review of the communicable disease picture in New Zealand today.

Communicable diseases were the fourth major cause of death in New Zealand between 1989 and 1993. New Zealand has higher rates of some vaccine preventable diseases than comparable developed countries. Periodic measles and pertussis epidemics are directly attributable to low rates of vaccination. Non-vaccine preventable diseases that occur in New Zealand at high rates compared to similar countries include meningococcal disease, rheumatic fever and enteric diseases. The latter includes campylobacteriosis, cryptosporidiosis and giardiasis. The incidence of verotoxigenic E. coli (VTEC), possibly the most important emerging enteric disease in the developed world, has risen markedly since 1997.

Drs Orchard, Baker and Martin also highlight the importance of emerging communicable diseases.

They go on to detail strategies for communicable disease prevention, including vaccination and wise use of antibiotics, and highlight the need for national and international strategies to detect and control the threat of communicable disease.

Against the background provided by the paper from Drs Orchard, Baker and Martin, Dr Ashley Bloomfield, Public Health Physician, National Health Committee provides an overview of prioritisation of health services in New Zealand.

He identifies the various bodies and organisations involved in prioritisation decisions at different levels, outlining how prioritisation decisions are made and considering the implications for communicable disease surveillance, prevention and control at each level of prioritisation.

Reviewing the central organisations involved in priority setting, Dr Bloomfield considers the roles of the Ministry of Health, the Health Funding Authority (HFA), which directly funds or purchases health and disability services for New Zealand, New Zealand’s drug management agency Pharmac, and the National Health Committee. The latter group is not directly involved in prioritisation decision-making but exists to advise the Minister of Health on the “kinds and relative priorities of public health, personal health and disability support services that should be publicly funded”. ²

Dr Bloomfield goes on to consider the various initiatives in place to increase the transparency and consistency of decision-making at the level of individual health professionals and service providers, including access and practice guidelines.

In the last part of his paper, Dr Bloomfield discusses what changes, if any, might occur in prioritisation processes under the health sector changes currently in progress in New Zealand. These include a new health sector structure comprising a merged Ministry of Health and HFA and the establishment of District Health Boards. Dr Bloomfield considers possible options for prioritisation decision-making within the new structure. He also considers possible changes in the process of priority setting at the level of Government and Cabinet.

Sally Wilkinson, Consultant and formerly a Director of the HFA, also refers to the various levels of decision-making in the area of health services prioritisation, from government through to clinicians working directly with the public. In particular she highlights the role of the HFA in a discussion of purchasing in the nineties. The establishment of a purchaser/provider split in the New Zealand health sector in 1993 made the prioritisation of resource allocation more transparent. She highlights several initiatives in the development of the purchaser role related to service prioritisation.

For example, the Coromandel Stakeholder process was used by the Midland Regional Health Authority to consult local communities and involve them in decision-making about provision and use of health services. The final output of the group was a recommendation to Midland Health on priorities in health and disability services that should be purchased on behalf of Coromandel residents.

Wilkinson closes by considering the challenges that the health sector faces in the current environment of change under the new Labour Government. HFA functions will be split between the Ministry of Health and a proposed 22 District health boards which will be responsible for regional service planning and delivery.

Drs Chris Bullen and Greg Simmons, Public Health Physicians, and Kathy Pritchard, Manager Disease Management Team, Auckland Healthcare Public Health Protection Service, Auckland New Zealand, offer a provider level view of communicable disease within the Auckland region. They consider the drivers of communicable diseases and the ways in which a mainstream Public Health Service can respond to communicable diseases, while adhering to the prioritisation agenda(s) established at various levels as discussed in the Bloomfield paper.

They consider four key infrastructural elements in public health that impact on prioritisation decisions in the management of communicable disease at a provider level: public health legislation, surveillance, human resources and funding.

The example of communicable disease outbreak management is used to illustrate the issues faced by a regional provider in prioritising activities. Outbreak control is always a priority, overriding most other public health activities. At an individual disease level, campylobacter infection investigation and control requires the setting of explicit priorities. Because over 2,000 cases are notified annually in Auckland, follow-up of sporadic cases is impossible because of a limited workforce and outbreaks of illness involving two or more people are given priority. Descriptive and analytical epidemiological techniques inappropriate to individual cases can be used to identify risk factors for infection and, in doing so, can allow control of hazards and the prevention of future illness.

References

1. Yamey G. Health secretary admits that NHS rationing is government policy. BMJ 2000; 320:10
2. National Advisory Committee on Health and Disability. Eighth Annual Report to the Minister of Health. Wellington: National Health Committee; 1999.