In the autumn of 2003 the County Council of Östergötland went all the way in terms of working with transparent horizontal priorities, and was the first county council in the country to do so. Preparations had then been underway for a number of years.
The aim of this report is to describe the political decision making process during the work with priority setting in Östergötland in 2003, and to analyse the process based on a condition that is of importance if a decision making process is to be considered fair and legitimate.
Some of the questions we initially had were:
- Are the politicians going to set any transparent priorities?
- What is the process like?
- What actors take part in the decisions?
- How do the politicians reason in order to arrive at decisions?
- What do the politicians take into account when making decisions?
- What are the obstacles to transparent priorities?
- What are the success factors?
Our method is based on acquiring information from many sources:
- Direct observation at the Public Health and Medical Services Committee’s (PHMSC) two practical priority setting exercises in March and in May 2003
- Direct observation at the PHMSC’s information meetings, working meetings and conferences, and the medical advisors’ meetings during September - October 2003.
- Interviews with participating politicians, medical advisors, public officials, the Health Care Director, and health professionals during December 2003 - January 2004.
- Examination of directives, background material, supporting documents for the decisions, and internal and external documents from the county council.
- Focus groups and a before-after questionnaire at the citizens’ meeting in January 2004.
An additional study focuses on how the priority setting process was reflected in daily newspapers during the autumn of 2003. The results of this study will be reported in an upcoming report.
Our observations and interviews show that the procedure for priority setting used in Östergötland functioned relatively well but that there were also shortcomings. In addition, we found that with respect to many points the decision making process fulfilled the required conditions for a decision making process to be considered fair and legitimate reasonable and accepted by the majority while several conditions were poorly dealt with.
1. The institution where the decisions are made
In accordance with current regulations for the County Council, decisions are made by the PHMSC following recommendations from its Presidium. The priority setting decisions were made in a legitimate organisational context with a mandate to make this type of decision.
2. The persons who participated in the decisions
Only politicians on the PHMSC took part in formal decision making, but during the preparatory phase with development of proposals for decisions, the Presidium of the PHMSC had the support of medical advisors, public officials, the Health Care Director, as well as administrative assistance. When making decisions, the politicians’ behaviour was consistently supportive. This contributed to making a joint political decision possible despite differences in political views and different opinions. Supporting documents in the form of vertical ranking lists and descriptions of consequences were furnished by the health professionals. When developing these documents for use in decision making, however, representation of professional groups other than physicians was often missing, as was that of “users”, i.e. patients and citizens. The perspectives of many interested parties were represented, while others that could have contributed were missing.
3. Factors considered in the decisions
Different individual factors that shaped the decisions are found in the priority setting model that was established in the County Council. The priority setting model is based on ethical principles established by the Swedish Parliament and contains components that are important to consider in priority setting. The politicians had a high level of awareness concerning principles and factors they should consider in their decisions, but in practical discussions they seldom referred directly to individual factors in the model for priority setting.
4. Reasons for the decisions
The politicians had not written down their reasons and motives at an early stage, which made transparent discussion difficult concerning both results and their underlying motives. The individual factors the politicians considered during their discussions were weighed together into different composite pictures, clusters of facts, that formed the reasons and motivations for the decisions. As a rule, reasons for decisions did not rest on individual factors, but on a total appraisal of facts.
5. The decision making process
The work fulfilled a number of conditions for the decision making process itself within a decision making group that contribute to fairness. We consider that there was great transparency within the decision making group, while there was less transparency toward other politicians and toward other actors in the priority setting process. There was also relatively great outward transparency toward the public. The supporting documents and the final document were published on the Internet. Although a large part of the material was available on the Internet, few knew that it was there and could interpret and understand its content. In other words, although the material was accessible it was nevertheless “inaccessible” to the public.
6. Mechanisms for appealing decisions
The intention of the County Council was that it would be possible for its first decisions to be appealed if new facts and arguments emerged. In this first round, however, there was no prepared mechanism for appealing decisions if new facts or arguments emerged.
The areas where we think there is the greatest need for improvement:
- Representation of groups other than physicians is needed in order to elucidate problems regarding the entire care chain, from prevention to care to rehabilitation. Greater representation or dialogue with “the users”, i.e. patients and citizens, is needed to obtain their perspective regarding health care policy priority setting and to assure that the priority setting procedure is considered to be fair and legitimate. However, it is necessary to identify appropriate problems about which to carry on a dialogue.
- An established routine in the decision making process is needed to assure that those who take part in the decisions consider all the components in the County Council’s model for priority setting.
- Concerning transparency in the decision making process, we consider it important for supporting documents to be developed by means of an transparent internal process that includes health care staff at many levels in order to attain as high internal legitimacy as possible. Sound information must therefore be given to participants’ own organisation: initially concerning the priority setting process, differentiation of roles, guidelines and timeframe; and at the conclusion of the priority setting process concerning what decisions mean in practice for the clinical areas. Guidelines for who should do what, how it should be done, and when it should be done must be clear. Information also needs to be given to the public: initially concerning how the work is carried out, and at the conclusion of the priority setting process concerning the decisions that have been made and a description of possible consequences. The information that is dispersed externally should as far as possible be well adapted and contain information about actual decisions, or preliminary positions the politicians want to convey for public debate.
- A mechanism for appealing decisions if new knowledge or new arguments emerge is lacking and should be created.
- Above all, transparency must increase with respect to decisions and reasons for decisions. The possibility of assessing and discussing priority setting decisions increases greatly if the decisions are well-motivated so that facts, values and the weighing of pros and cons are reported.
Linköping: Linköping University Electronic Press, 2004. , 58 p.