S HOULD WE MAKE THE PRIORITY SETTING PROCESS MORE EXPLICIT TO THE PUBLIC ? D R B ENEDICT R UMBOLD

SHOULD WE MAKE THE PRIORITY SETTING PROCESS MORE EXPLICIT TO THE PUBLIC?

DR BENEDICT RUMBOLD

‘PAY NO ATTENTION TO THE MAN BEHIND THE CURTAIN!’

• At present, priority setting process is

semi-public; the curtain has been drawn back,

but not completely.

• The public are aware that priority setting takes

place but not:

– Who is responsible for decision making

– What basis decisions are made on

• We need to decide whether to either:

a) Make the process more transparent

b) Publicly endorse an obscurity – be ‘explicitly

implicit’ (Chinitz, 1998)

Toto reveals the Wizard - The Wizard of Oz (1939)

CURRENT PRACTICE IN THEENGLISH NATIONAL HEALTH SERVICE

• Questionnaires sent out to all 152

Primary Care Trusts in England.

• 115 responses from 74 out of 152 PCTs

(49%).

• Survey results suggest that 70% of PCTs

have a formal priority setting boards.

• Respondents asked to highlight which

aspects of the priority setting process

PCTs make available to the public.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%91%

44% 45%42%

50%

22%

3%9%

QUESTION: WHICH OF THE FOLLOWING ASPECTS OF THE PRIORITY SETTING PROCESS DOES YOUR

PCT MAKE EXPLICIT TO THE PUBLIC?

THE CASE FOR PUBLICITY

© Getty Images

• Argument from rights - Public has a

‘right to know’.

• Argument from democracy and

fairness – Publicity is necessary for

informed consent and fair dealings.

• Argument from pragmatism -

Publicity guards against

inconsistency, unjust preferences

and groundless exceptions.

WHY DO PRIORITY-SETTERS MAKE THE PROCESS SO

UNCLEAR?• Interviews yet to take place – but working hypothesis is they

want to avoid blame.

• But what is blame and why are priority-setters so concerned

about it?

• Blame:

– Perception of harm

– Perception of responsibility

• Worry of priority-setters is that, by its very nature, priority-

setting involves causing harm – e.g. by denying healthcare to

people who would benefit from it.

• So, blame is seen as inevitable, hence their interest in strategies

of blame-avoidance (especially limiting perceptions of

responsibility).

PRIORITY-SETTING AND VAGUENESS

• Within the priority-setting process, who makes the decisions,

and the basis on which decisions are made is not always clear

cut.

– E.g. a decision may be the result of many actors working

together and/or independently, each of whom may be

relying, say, on moral intuition rather than a definitive set

of principles.

• However, in the public sphere, vagueness in either the decision-

making process or on the part of the decision makers

themselves is usually frowned upon.

• As such, actors may be unwilling to take responsibility for their

part in a vague system, given vagueness is accepted within the

system but castigated outside it.

© Getty Images

PERSUADING ACTORS TO MAKE THE PRIORITY SETTING PROCESS EXPLICIT

• Raise the possibility of praise? Unlikely to be effective …

a) Typically, decision-makers are so fearful of blame they would prefer to avoid taking any

responsibility even if that meant giving up possibility of praise (Weaver, 1986)

b) In order for priority-setters to be praised there needs to be some perception of benefit.

But, as established, priority-setting always results in some kind of harm.

The best a priority-setter can hope for is the public praising them for fairly

distributing harms – unlikely to receive much praise for this.

• Instead, priority-setters need to be persuaded either:

a) That allowing for the possibility of blame is a price worth paying.

b) Not all publicity need lead to blame.© Getty Images

Hood suggests blame can:

• Encourage decision-makers to ‘win the

argument’.

• Improve the delegation of responsibility

within decision-making hierarchies.

• Encourage decision-makers to follow set

rules and processes – to ‘take care’. (Hood, 2010)

PUBLICITY CAN BE GOOD, EVEN IF IT MEANS MORE BLAME

National Library NZ

COMPLETE PUBLICITY HAS COSTS• Complete publicity can negatively effect the decision-making process:

– Moving from private, particularistic reasons to truly public reasons may then often have an

associated price, i.e., shifting from profound (private) reasons to shallow or manipulative (public)

reasons (Chambers, 2004).

• Also, complete publicity rarely allows for vagueness, and vagueness in the priority-setting

process may not only be necessary but also something we want to hang on to (e.g.

Mechanic, 1997).

The villagers confrontFrankenstein –Frankenstein (1931)

RATIONING AND REACHING THE POINT OF TRUST

• Need a level of publicity that allows for

responsibility and public knowledge but

which also allows for the possibility of

vagueness.

• One possible option is combining an explicit

model with a sustained effort to increase

public trust in priority-setters themselves.

• Trust may give priority-setters the elbow

room to be vague, and to avoid shallow or

manipulative (public) reasons – i.e. to be

explicitly implicit.

© Getty Images

www.nuffieldtrust.org.uk

benedict.rumbold@nuffieldtrust.org.uk

REFERENCES

• Chambers, S (2004) “Behind Closed Doors: Publicity, Secrecy, and the Quality of

Deliberation”, Journal of Political Philosophy 12(3): 389-410

• Chinitz, D., Shalev, C., Galai, N. & Israeli, A. (1998) ‘Israel’s basic basket of health

services: the importance of being explicitly implicit’, BMJ, 317, 1003-7

• Hood, C (2010) ‘Risk and Government: The architectonics of blame-avoidance’,

Darwin College Lecture Series - February 2010

• Mechanic, D., (1997), ‘Muddling Through Elegantly: Finding the proper balance in

rationing’, Health Affairs 16 (5) 83-92.

• Weaver, R K (1986) ‘The Politics of Blame Avoidance’ Journal of Public Policy 6 (4):

371-98.