s hould we make the priority setting process more explicit to the public ? d r b enedict r umbold
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SHOULD WE MAKE THE PRIORITY SETTING PROCESS MORE EXPLICIT TO THE PUBLIC?
DR BENEDICT RUMBOLD
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‘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)
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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.
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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?
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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.
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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).
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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
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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
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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
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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)
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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
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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.