Public Health Module Venue Date Making ethical decisions
Public Health Module Venue Date Making ethical decisions in commissioning Author: Andrew Harris Governance Consultant, Solicitor, former GP and Public Health Consultant andrew@adrharris. co. uk AH/HK@2010 ADR Harris Ltd
1. The Quality of the group decision 09. 30 am – 09. 40 am AH/HK@2010 ADR Harris Ltd
Plenary Discussion Point 1 v How good is decision making in health care commissioning? AH/HK@2010 ADR Harris Ltd
Why poor decision making? • • Crisis management, lack of time Lack of skills Applying literature difficult No systematic approach to rationing Lack £ analysis underpins commissioning Over- reliance on cost effectiveness Group think AH/HK@2010 ADR Harris Ltd 4
Group think • Illusion of invulnerability • Leaders are protected from contradictory evidence • Members reject information which does not fit and do not consider alternatives • Individuals with minority views discounted • Planners asked to critique them Hammond Keeney Raiffa, Harvard Business Review, 2000 AH/HK@2010 ADR Harris Ltd
Asch’s cards A B C Solomon Asch 1951 AH/HK@2010 ADR Harris Ltd
Social influences Some decision makers are influenced by a desire to • • please others avoid conflict be seen as part of group avoid criticism of unpopular decision AH/HK@2010 ADR Harris Ltd
Plenary Discussion point 2 There was no Elgar Collaborative, nor was Harry Potter written by an Edinburgh Writers’ Network v Will a group make better decisions than one or two qualified individuals? AH/HK@2010 ADR Harris Ltd
Conditions for Group Decisions • • • Ensure time and skills Have relevant information – local knowledge Ensure decision process clarifies diverse views Independence - minimize social influences Have systematic process for prioritising and aggregating views From Surowiecki, Wisdom of Crowds, 2004 AH/HK@2010 ADR Harris Ltd
2. The process of bringing together individuals’ views 09. 40 am – 10. 40 am AH/HK@2010 ADR Harris Ltd
Group Discussion point 3 v Why do people have different priorities? v How then does a group of individuals handle these different views? AH/HK@2010 ADR Harris Ltd
Different priorities • People have different instincts, values, assumptions, knowledge, perceptions, experience… • People have different roles in their work which create priorities AH/HK@2010 ADR Harris Ltd
Managing different priorities • Group needs to have own “personality” with values, assumptions, knowledge, etc • Share individual views and contribute to view of corporate personality AH/HK@2010 ADR Harris Ltd
Commissioning - on what do you base a decision? To make a decision, the group should have: 1. 2. 3. 4. Underlying values or principles Considerations Criteria Relevant information AH/HK@2010 ADR Harris Ltd
Plenary Discussion point 4 v Where do your underlying values and principles come from? v From where should the group get its underlying principles and values? AH/HK@2010 ADR Harris Ltd
Values and principles • • Initially from the family; society norms With maturity, adopt their own PCT Family – Staff and leadership of [insert name of org], other organizations and communities; Society - the NHS • Will wish to adopt the norms of the NHS whatever think of family!! AH/HK@2010 ADR Harris Ltd
[name of local organization] Insert below the key values from the Commissioning Strategic Plan or mission statement. Examples of what might be found: • • Person at centre Improve health; reduce health inequalities Improve quality and safety; leadership Choice and Accessibility Partnership Local sensitivity Visibly credible and efficient AH/HK@2010 ADR Harris Ltd
[local organization subgroup] Examples of principles that may be found: • • Clinical need – best possible outcome Clinical effectiveness, appropriateness Cost Effective – QALY, value, not cost alone Equity – service development and precedence Accessibility, choice, comprehensiveness Quality and patient experience Lawfulness AH/HK@2010 ADR Harris Ltd
NHS Constitution Key principles • Comprehensive, non discriminatory, equality • Access related to need not ability to pay • Excellence, innovation, leadership • Reflect needs of patients /families • Partnership beyond health • Best Value for Money (VFM), sustainable effective use £ • Accountable – public, patients, community NHS Constitution 2009 AH/HK@2010 ADR Harris Ltd
Group Discussion point 5 • Look at various principles and consider any others • If you have any priorities, individually write down your top two Explain priorities and discuss with colleagues any differences __________________________________ Hand out slides up to here AH/HK@2010 ADR Harris Ltd
2. The process of bringing together individuals’ views (continued): Hand out AH/HK@2010 ADR Harris Ltd
Commissioning Principles • • • Relevance to community and health gain Equity and access Effectiveness and appropriateness Responsiveness Comprehensiveness and partnership Efficiency and affordability From Maxwell RJ and various NHS sources AH/HK@2010 ADR Harris Ltd
Principles in Tension • Responsiveness to need and affordability • Clinical effectiveness and responsiveness to demand for other outcomes/ treatments • Equity of access or equity of outcome • Access and efficiency • Declining exceptional treatment and comprehensiveness AH/HK@2010 ADR Harris Ltd
Commissioning - ethical decision making • How does a PCT resolve conflicts between common principles? • Can ethics help improve group decision making and resolve conflicts of interest? AH/HK@2010 ADR Harris Ltd
What is ethics? • • Not science – doesn’t direct conduct Not religion – selected ethics and people Not norms – cultures vary Principles related to right or wrong conduct AH/HK@2010 ADR Harris Ltd
Types of ethics • Individual – morality • Professional – codes of practice • Corporate – governance and policy AH/HK@2010 ADR Harris Ltd
Individual Belief: • Patient autonomy • Benevolence • Preventing harm • Justice Conduct: • Honesty and integrity AH/HK@2010 ADR Harris Ltd
Plenary Discussion Point 6 v In what way are ethical principles and conduct different for health professionals? AH/HK@2010 ADR Harris Ltd
Professional Additional • Objectivity • Openness • Confidentiality • Integrity Conduct • Compliance with codes • Duty of care - legal AH/HK@2010 ADR Harris Ltd
Group Discussion Point 7 v In what way are ethical principles or conduct different for a PCT compared with an individual? AH/HK@2010 ADR Harris Ltd
PCT Different because • Org values/processes tension with individual conscience • Conflicts of interest affect many - provider/commissioner • Social justice /long term v individual/ short term • Public service context – situational ethics • Duty of leadership to influence others Conduct • Compliance with DH / Commissioning principles • Statutory duties see The Quest for Public Service Ethics, G E Kyarimpa, J-C Garcia Zamor, Public Money & Management, Jan 2006 AH/HK@2010 ADR Harris Ltd
NHS Constitution Values • Respect and dignity - listening • Commitment to quality – integrity, accountability, communication • Compassion, time for people • Improving lives, value excellence • Working together – put patients first • Everyone counts – some more help AH/HK@2010 ADR Harris Ltd
[Local organization] Example of vision and values from a CSP • People centred • Support self responsibility for own health • Innovative and continuous improvement • Open honest communication • Diversity and non discrimination • Understanding, dignity and respect • Accountability – work, resources, environment AH/HK@2010 ADR Harris Ltd
Corporate • What principles can be adopted that will assure others to trust the way the decision was taken was proper? AH/HK@2010 ADR Harris Ltd
Corporate principles - Nolan • Selflessness - the public interest • Objectivity – make choices on merit • Integrity – no obligations to others • Honesty – declare and resolve conflicts of interest • Openness – Share info, give reasons for decisions • Accountability – explain, scrutiny • Leadership – promote principles by example AH/HK@2010 ADR Harris Ltd
Corporate ethical approach? • If we adopt Nolan principles do we resolve the conflicts between individual views? • If we are ethical, can we say we have taken the right decision as well as taking it in the right way? AH/HK@2010 ADR Harris Ltd
Ethical Approaches Utilitarian Mills Bentham Consequentialist Rule, Ends Efficient, Cost benefit, Health gain • Organisational targets • Common good - society Plato • Hierarchies and markets Kantian Moral intention, Rules Comprehensive, Equity, Clinical Effect • Professional duty of care • Inflexible – John Rawls • Hierarchies not markets Rights Ethics of care UN Individual in community Autonomy, Responsiveness • Duties to known - clinicians • Partnerships and networks • Not hierarchies or markets Virtue Aristotle Moderate conduct Nolan principles • Keep core values Procedural • Context and impact – ? Equity • Flexibility, No Consistency From Governance, Ethics and NHS, K Morrell, Public Money & Management, Jan 2006 AH/HK@2010 ADR Harris Ltd
Application of ethics • Nolan - template of conduct of corporate personality - avoid social influences and conflicts of interest • Also need ethical framework to surface perceptions • Is any one ethical stance best? e. g. legal duty – “right” • Ethics training facilitates harmonising individual and corporate values • Best way to uphold ethics is if organisation norms, rules, standards are incorporated in individual ethics Half Full or Half Empty? British Public Sector Ethics, A Doig, Public Money & Management, Jan 2006 Achieving the Ethical Workplace The Ethics Edge, E Berman (Ed) S Bonczek ICMA, Washington 1998 AH/HK@2010 ADR Harris Ltd
3. The process of deciding – legal decision making 10. 40 am – 10. 50 am AH/HK@2010 ADR Harris Ltd
Legal decisions • When does the law make a principle greater priority? • Are all legal decisions ethical? • Can we be found to have acted illegally but ethically? AH/HK@2010 ADR Harris Ltd
Legality of decisions • Statutory duties • Public law Process > merits • Human Rights – ECHR Proportionality in context AH/HK@2010 ADR Harris Ltd
Statutory Duties • 1946 Provision – delegated (2002) “all reasonable requirements”, without charge • 1998 Quality (2003) • 1999 Break even, Partnership • 2004 Procurement (EU) • 2006 Involve patients, Equality £ allocation and resource use limits • 2009 Innovate? The role of PCT board in world class commissioning DH Nov 08 AH/HK@2010 ADR Harris Ltd 42
Rights in NHS Constitution • • 24 – many not new rights; probably expanded JR Services to meet locally assessed need Treatment in EC countries in certain circs No age discrimination in services (Eq Act) Required levels of safety in registered orgs Monitor /improve quality (SDQ) + commissioning NICE TAs; decisions on drugs rational and proper consideration of evidence AH/HK@2010 ADR Harris Ltd
Judicial Review • Illegality – beyond powers – irrelevant considerations – fettering discretion • Irrationality/ Unreasonableness – judicial deference • Procedural Propriety – fair, info to applicant AH/HK@2010 ADR Harris Ltd 44
European Convention of Human Rights (ECHR) law Human Rights Act (HRA) 1998 • Awareness of ECHR by staff • A 2 – Life • A 3 – Dignity • A 8 – Family life and correspondence • A 14 – Equality – no blanket ban AH/HK@2010 ADR Harris Ltd 45
Proportionality • European Commission and ECHR law - replaces irrationality • Interference with Rights v legitimate aim - damage to individual v gains from interference - no less restrictive intervention • Qualified Rights - A 8 Family life: balance individual need with community interests AH/HK@2010 ADR Harris Ltd 46
Law and decisions • Law informs whether decision making process was right • Some laws or decisions might be challenged on ethical grounds - ECHR • Different decisions on funding or commissioning might both be legally sound decisions in different contexts or using different processes • Need a framework to ensure legal and ethical process and balance conflicts AH/HK@2010 ADR Harris Ltd
Law and Accountability • • Corporate legal and £ accountability Ethics play each time any group decides Always individual professional accountability Many networks and partnerships – clarify characteristics, GBO 48
Coffee 10. 50 am – 11. 10 am AH/HK@2010 ADR Harris Ltd
4. Balancing stakeholders 11. 10 am – 12. 10 pm ADR Harris Ltd AH/HK@2010 andrew@adrharris. co. uk ADR Harris Ltd
Stakeholder theory • • More than investors, employees, suppliers, customers Legal duties bring moral duties - Rawls fairness Stakeholders – helpers eg communities or hold power Stakeholder communication is good for org – better able to assess goals – easier to take advantage of unforeseen opportunities – enables aversion of conflict before critical stage • Balance voice in decision making according to contribution, relevance Strategic Management: A Stakeholder Approach, R Edward Freeman, 1984 Stakeholder Theory and Organizational Ethics, Robert Phillips, 2003 AH/HK@2010 ADR Harris Ltd
[Group Exercise] Preparation • Read scenario application for funding and cases of the stakeholders • Think what considerations are necessary to apply the principles • Consider stakeholder views and how they should be weighted AH/HK@2010 ADR Harris Ltd
Stakeholders Case Manager for Patient Case for Science Autonomy, Responsiveness, Comprehensiveness Beneficence, Malfeasence, Effectiveness • Clinical benefit, patient view • Consistency/ procedure • Human rights • clinical and cost effectiveness • seeking normative opinions • capacity to benefit Case for Community Health Gain Justice, Equity, Relevance • Apply commissioning priorities • Impact on other services, groups AH/HK@2010 Case for £ • • • ADR Harris Ltd Efficiency, Affordability Impact on PCT resources Cost of meeting similar need VFM alternative providers 53
[Small group discussions] v What considerations are necessary to address the agreed ethical principles, legal duties and commissioning principles? v Seek clarification / info from stakeholders v Using principles and stakeholders, and Nolan principles for the way the group behaves, begin decision making process AH/HK@2010 ADR Harris Ltd
[Feedback] v Each group to report back on what tensions in the decision making process and what approach to resolution v Stakeholders to make brief comment ____________________ Second Handout of slides up to here AH/HK@2010 ADR Harris Ltd
Session 5 Hand out AH/HK@2010 ADR Harris Ltd
5. An ethical decision making framework for commissioning 12. 10 pm – 12. 20 pm AH/HK@2010 ADR Harris Ltd
Frameworks • Process of bringing together all needed to make good decision - governance • Many PCTs follow the Harris Framework: PCT Decision Making in Priorities Panels: a Review of the literature and management of decision making processes in resource allocation for commissioning treatments; Recommendations for PCTs and SHAs, October 2006; andrew@adrharris. co. uk • Openness, Efficiency, Fairness, JR proof AH/HK@2010 ADR Harris Ltd
Commissioning - on what do you base a decision? To make a decision, the organisation or network should have: 1. 2. 3. 4. Underlying values or principles Considerations Criteria Relevant information AH/HK@2010 ADR Harris Ltd
Ethics Honour as far as possible ethical principles and ensure awareness of them and an appropriate balance between them in structure and governance of the organisation: • Patient autonomy • Beneficence • Non malfeasance • Justice AH/HK@2010 ADR Harris Ltd
Law Recognise main legal duties of public bodies to ensure that the decisions withstand JR: • • • Meeting statutory duties Legality (acting within powers) Reasonableness Proportionality Procedural Propriety Equality/non discrimination AH/HK@2010 ADR Harris Ltd
Commissioning principles Adopt principles for resource allocation decisions and ensure appropriate balance between them in decision-making: • • • Relevance to community and Health gain Equity and Access Effectiveness and Appropriateness Responsiveness, Comprehensiveness and Partnership Efficiency and Affordability AH/HK@2010 ADR Harris Ltd
Commissioning - on what do you base a decision? To make a decision, the PCT should have: 1. 2. 3. 4. Underlying values or principles Considerations Criteria Relevant information AH/HK@2010 ADR Harris Ltd
Considerations - 1 • Legality of funding decision • Clinical needs of patient/group of patients - clinician’s and normative view • Evidence of clinical effectiveness • Whether needs can be met by alternative means • Cost effectiveness, balance of risk and benefits, capacity to benefit, clinical governance requirements • Impact of provision of treatment on PCT resources AH/HK@2010 ADR Harris Ltd
Considerations - 2 • Consistency: impact of providing similar treatment to other PCT residents with similar needs • Impact of funding decision on health of population • Impact on other services for which £ is not then available • Patient views • Potential human rights considerations and proportionality • Procedural propriety, transparency and probity AH/HK@2010 ADR Harris Ltd
Commissioning - on what do you base a decision? To make a decision, the PCT should have: 1. 2. 3. 4. Underlying values or principles Considerations Criteria Relevant information AH/HK@2010 ADR Harris Ltd
Criteria Priority setting policy assisted by adopting criteria. Choice of each PCT, e. g. : • Weighting or tending to exclude an application e. g. incremental cost effectiveness thresholds • Prior categorisation into low or high priority commissioning lists • Approval/non approval – Network or DTC AH/HK@2010 ADR Harris Ltd
Commissioning - on what do you base a decision? To make a decision, the PCT should have: 1. 2. 3. 4. Underlying values or principles Considerations Criteria Relevant information AH/HK@2010 ADR Harris Ltd
Relevant information Info needed (? application form) e. g. : Consistency: Precedence previous £ applications, freq of illness, cost of funding all group, exceptional circs Human rights: ? interfere with Human Rights; ? fundamental ? alternative, ? justified, proportionality: harm v benefit Procedural: patient informed of choices, communication; opportunity to make case; relevant considerations; declare of conflicts of interest; records of discussions AH/HK@2010 ADR Harris Ltd
Decision making framework • Values and principles – Ethics and Nolan – Law – Commissioning principles • Considerations • Criteria • Relevant information AH/HK@2010 ADR Harris Ltd
Audit of Decision Making Accountability for Reasonableness • Rationale uses reasons and principles relevant to those seeking mutually justifiable solution • Decisions and rationale publicly accessible • Mechanism for dispute resolution • Formal regulation of process • Effective opportunity for all stakeholders to independently submit relevant considerations Accountability for reasonableness: an update, N Daniels, JE Sabin, BMJ 2008: 337, 1850 AH/HK@2010 ADR Harris Ltd
End Evaluation + Hand out slides AH/HK@2010 ADR Harris Ltd
Participant Evaluation • Lilac = What did you learn? • Yellow = What worked well for you in the workshop • Blue = Is there anything you would do differently, if so, what and how? • Green = What are your future needs? AH/HK@2010 ADR Harris Ltd
- Slides: 73