Phil Shackleyand Mandy Ryan
Health Economics Research Unit, University of Aberdeen, Scotland Abstract
This paper considers ways of involving consumers in decisions regarding the allocation of scarce health service resources. Specifically, two levels of consumer participation are highlighted and discussed. These are: (1) at the level of deciding whether or not a particular service should be introduced or its scale changed; and (2) at the level of deciding how best to provide a service once it has been decided that the service will be provided. The limitations of the current methods of involving consumers are outlined and two alternative approaches discussed. These are willingness to pay and conjoint analysis.
Limited resources coupled with unlimited d e m a n d for health care mean that decisions have to be m a d e regarding the allocation of scarce resources across competing health care interventions. Traditionally, the extent of consumer (patient) involvement in this decision making process has been minimal. However, with the advent of the recent reforms of the UK National Health Service (NHS), greater consumer involvement has been advocated. 1-3 A policy emphasis on increasing patient choice and the implication that this is a good thing indicates that the UK government envisages consumers in the 'new' NHS as having a m u c h more active role in health care decision making. Although the background to this paper is the recent reforms of the UK National Health Service, the concepts discussed are relevant to any health care system in which community values a n d / o r patient preferences are elicited. In this p a p e r w e consider ways of involving consumers in decisions regarding the use of
scarce health care resources. Consumer involvement is considered at two distinct levels. The first concerns decisions about w h e t h e r or not a particular service should be introduced or its scale changed (extended or contracted). In economics terminology, this level of decision making is concerned with allocative 9yiciency. The second level is concerned with the best w a y of providing a particular service once it has been decided that the service will be provided. In the terminology of economics, this level of decision making is concerned with technical efficiency. Each of these decision making levels will be discussed in turn. In doing so, the limitations of existing methods of involving consumers are outlined and alternative innovative approaches are suggested which not only educate and inform consumers, but also m a k e clear the trade-offs that exist.
Should A Service Be Provided (Or Its Scale Changed)?
The NHS Management Executive with the publication of its d o c u m e n t Local Voices has stimulated purchasers to take more account of the wants of local people w h e n setting health care priorities. 4 The M a n a g e m e n t Executive's initiative has forced purchasing authorities to
Phil Shackley and Mandy Ryan, Health Economics Research Unit, Department of Public Health, University of Aberdeen, University Medical Buildings, Foresterhill, Aberdeen, AB9 2ZD, Scotland CCC 1065-3058/95/030196-09 9 1995 by John Wiley & Sons, Ltd.
consider the opinions of the local community in their purchasing decisions. They have been directed to purchase more services on the basis of wants rather than needs, implying less weight being given to results of needs assessment exercises vis-?z-vis community values. In principle, the elicitation of community values represents a big step forward in terms of enhancing consumer participation in health care. However, for the exercise to be a useful one, purchasers have to be able to use the values. Whether or not they will be able to will depend upon the method used to elicit the values. The emphasis of Local Voices is on market research techniques, such as opinion polls. One example of such an...