Setting priorities for high-cost medications in public hospitals in Australia: should the public be involved?Gisselle Gallego A B F , Susan J. Taylor C and Jo-anne E. Brien C D E
A Centre for Health Economics Research and Evaluation (CHERE), University of Technology, Sydney, PO Box 123, Broadway NSW 2007, Australia.
B Faculty of Health Science, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia.
D Therapeutics Centre, Level 2, Xavier Building, St Vincent’s Hospital, Sydney, Darlinghurst, NSW 2010, Australia. Email:email@example.com
E Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia.
F Corresponding author. Email: firstname.lastname@example.org
Australian Health Review 35(2) 191-196 https://doi.org/10.1071/AH09746
Submitted: 16 February 2009 Accepted: 25 August 2010 Published: 25 May 2011
Aim. To explore healthcare decision makers’ perceptions about public involvement in setting priorities for high-cost medications (HCMs) in public hospitals in Australia.
Methods. In-depth, semi-structured interviews were conducted with 24 decision-makers (executive directors of hospitals, area health service managers, directors of hospital pharmacy departments and senior medical doctors) in a Sydney Area Health Service. Interviews were digitally recorded, transcribed verbatim, thematically content analysed and coded.
Results. The majority of participants perceived that the ‘rationing debate’ needs to happen in Australia. The community at large should be encouraged to understand that healthcare resources are limited and choices need to be made. The perspectives of the public, according to participants, were considered diverse (tax payers, patients, consumers). Owing to the complexities of the healthcare system, their involvement of the public in decision-making regarding access to HCMs in public hospitals was considered limited. For participants, the role of the public was likely to be at the macro level, deciding how much they were prepared to spend on healthcare.
Conclusion. The role of the public in setting priorities for HCMs in public hospitals was perceived by these healthcare decision makers as limited. However since rationing is unavoidable, there should be an explicit debate about the principles and issues concerned.
What is known about the topic? Recognition of the importance of engaging the public in healthcare decision making is increasing. However, there is only limited understanding of the role of citizens in current priority setting mechanisms for allocating scarce resources to high-cost technologies such as medications at the public hospital level.
What does this paper add? This study describes how involving the public in setting priorities for HCMs can present specific challenges from the perspective of decision makers working in the public hospital system.
What are the implications for practitioners? In a time when public awareness is increasing about medical advances the challenge is to find ways of informing and involving the public in the debate about the distribution of healthcare resources. The results from this study will be useful for policy makers working on ways to improve the legitimacy of decisions at the institutional level.
Additional keywords: decision-making, priority setting.
References Impacts of advances in medical technology in Australia: Productivity Commission research report. Melbourne: Australian Government Productivity Commission; 2005.
 Lindblad AK, Hartzema AG, Jansson L, Feltelius N. Patients’ views of priority setting for new medicines. A qualitative study of patients with rheumatoid arthritis. Scand J Rheumatol 2002; 31 324–9.
| Patients’ views of priority setting for new medicines. A qualitative study of patients with rheumatoid arthritis.CrossRef | 12492246PubMed |
 Funding arrangements for outpatient use of high cost drugs not funded by the Commonwealth. Circular No. 2004/73. NSW Department of Health; 2004.
 Salked G, Mitchell A, Hill S. Pharmaceuticals. In Mooney G, Scotton R, editors. Economics and Australian Health Policy. Sydney: Allen & Unwin; 1999. pp. 115–36.
 Sansom L. The subsidy of pharmaceuticals in Australia: processes and challenges. Aust Health Rev 2004; 28 194–205.
| The subsidy of pharmaceuticals in Australia: processes and challenges.CrossRef | 15527399PubMed |
 Hospital price and resource allocation review: good practice model for controlling medicines costs in hospitals. Melbourne: Victorian Therapeutic Advisory Group (VicTAG); 2004.
 Tan EL, Day RO, Brien JA. Prioritising drug and therapeutics committee (DTC) decisions: a national survey. Pharm World Sci 2007; 29 90–6.
| Prioritising drug and therapeutics committee (DTC) decisions: a national survey.CrossRef | 17187221PubMed |
 Moving forward – The funding of medicines in Australia’s hospitals. Melbourne: The Society of Hospital Pharmacists of Australia (SHPA); 2004.
 Gallego G, Melocco T, Taylor S, Brien J. Access to high-cost drugs: decision makers’ perspectives. Journal of Pharmacy Practice and Research 2005; 35 18–20.
 Kaye KI, Lu CY, Day RO. Can we deny patients expensive drugs? Australian Prescriber 2006; 29 146–8.
 Coulter A. Perspectives on health technology assessment: response from the patient’s perspective. Int J Technol Assess Health Care 2004; 20 92–6.
| Perspectives on health technology assessment: response from the patient’s perspective.CrossRef | 15176184PubMed |
 Citizens Council. National Institute of Clinical Excellence; 2004. Available at http://www.nice.org.uk/aboutnice/howwework/citizenscouncil/citizens_council.jsp [verified 21 July 2010].
 Jeyanathan T, Dhalla I, Culyer T, Levinson W, Laupacis A, Martin DK, et al. Recommendations for Establishing a Citizens’ Council to Guide Drug Policy in Ontario. Toronto: Institute for Clinical Evaluative Sciences; 2006.
 Johnson A, Silburn K. Community and consumer participation in Australian health services – an overview of organisational commitment and participation processes. Aust Health Rev 2000; 23 113–21.
| Community and consumer participation in Australian health services – an overview of organisational commitment and participation processes.CrossRef | 1:STN:280:DC%2BD3M%2FmtlersQ%3D%3D&md5=f26d44c6e4fc1d4a183bd9f86a56ad1eCAS | 11186043PubMed |
 Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Public participation in health care priority setting: a scoping review. Health Policy 2009; 91 219–28.
| Public participation in health care priority setting: a scoping review.CrossRef | 19261347PubMed |
 Contandriopoulos D. A sociological perspective on public participation in health care. Soc Sci Med 2004; 58 321–30.
| A sociological perspective on public participation in health care.CrossRef | 14604618PubMed |
 Murie J, Douglas-Scott G. Developing an evidence base for patient and public involvement. Clinical Governance: An International Journal 2004; 9 147–54.
| Developing an evidence base for patient and public involvement.CrossRef |
 Travaglia J, Braithwaite J. Public Involvement in Health Services: Literature review, selected citations and abstracts. Sydney: The Centre for Clinical Governance in Health, University of New South Wales; 2006.
 Charles C, DeMaio S. Lay participation in health care decision making: a conceptual framework. J Health Polit Policy Law 1993; 18 881–904.
| Lay participation in health care decision making: a conceptual framework.CrossRef | 1:STN:280:DyaK2c7msFChtQ%3D%3D&md5=74d5424be217e3cc44172df13f41f5fbCAS | 8120350PubMed |
 Bowling A, Jacobson B, Southgate L. Explorations in consultation of the public and health professionals on priority setting in an inner London health district. Soc Sci Med 1993; 37 851–7.
| Explorations in consultation of the public and health professionals on priority setting in an inner London health district.CrossRef | 1:STN:280:DyaK2c%2FisVWmsw%3D%3D&md5=239b9c0f2f72ead090fb6db1947c6247CAS | 8211302PubMed |
 Bowling A. Health care rationing: the public’s debate. BMJ 1996; 312 670–4.
| 1:STN:280:DyaK287ot1Ojug%3D%3D&md5=2b71d863769d7e87b70b844b79d55c5bCAS | 8597733PubMed |
 Mooney GH, Blackwell SH. Whose health service is it anyway? Community values in healthcare. Med J Aust 2004; 180 76–8.
| 14723590PubMed |
 Griffith G. Commonwealth-state responsibilities for health: ‘Big Bang’ or incremental reform? Briefing paper No. 17/06. Sydney: Parliament of NSW; 2006.
 Pope C, Mays N. Qualitative methods in health and health service research. In Mays N, Pope C, editors. Qualitative Research in Health Care. London: BMJ Publishing Group; 1996, pp. 1–9.
 Strauss AL, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd edn. Thousand Oaks: Sage Publications; 1998.
 Patton MQ. Qualitative Research and Evaluation Methods. 3rd edn. Newbury Park: Sage Publications; 2002.
 Smee CH. Bridging the gap between public expectations and public willingness to pay. Health Econ 1997; 6 1–9.
| Bridging the gap between public expectations and public willingness to pay.CrossRef | 1:STN:280:DyaK2s3oslCgtw%3D%3D&md5=72b96138185251de6e2df97c0a6b381fCAS | 9142527PubMed |
 Kenyon G. Doctors refuse to operate on 80 year old man. BMJ 1998; 317 1548
| 11645129PubMed |
 Tauber AI. Medicine, public health, and the ethics of rationing. Perspect Biol Med 2002; 45 16–30.
| Medicine, public health, and the ethics of rationing.CrossRef | 11796928PubMed |
 Tauber AI. Putting ethics into the medical record. Ann Intern Med 2002; 136 559–63.
| 11926802PubMed |
 Holm S, Sabin J, Chinitz D, Shalev C, Galai N, Israeli A. The second phase of priority setting. BMJ 1998; 317 1000–7.
| 1:STN:280:DyaK1M%2FitlWjug%3D%3D&md5=13f733da837e824ae64ab859b9b11cefCAS |
 New B. The rationing agenda in the NHS. Rationing Agenda Group. BMJ 1996; 312 1593–601.
| 1:STN:280:DyaK283mvVKkug%3D%3D&md5=cff65f426264d64a3a34b95aef45190fCAS | 8664673PubMed |
 Williams A. Medicine, economics, ethics and the NHS: a clash of cultures? Health Econ 1998; 7 565–8.
| Medicine, economics, ethics and the NHS: a clash of cultures?CrossRef | 1:STN:280:DyaK1M%2FlvFersQ%3D%3D&md5=cc6583bbd3120c9ee05359064576eff0CAS | 9845250PubMed |
 Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. J Health Serv Res Policy 2001; 6 163–9.
| Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices.CrossRef | 1:STN:280:DC%2BD3MvhvVCksg%3D%3D&md5=b77104e6105873f7b5b22bb0e7a87125CAS | 11467274PubMed |
 Gallego G, Taylor SJ, McNeill P, Brien JA. Public views on priority setting for high cost medications in public hospitals in Australia. Health Expect 2007; 10 224–35.
| Public views on priority setting for high cost medications in public hospitals in Australia.CrossRef | 17678511PubMed |
 McKie J, Shrimpton B, Richardson J, Hurworth R. Treatment costs and priority setting in health care: a qualitative study. Aust New Zealand Health Policy 2009; 6 11
| Treatment costs and priority setting in health care: a qualitative study.CrossRef | 19416546PubMed |
 Robotham J. Cancer drug gives hope, and a huge bill. Sydney Morning Herald 2004; (9 December). Available at http://www.smh.com.au/news/National/Cancer-drug-gives-hope-and-a-huge-bill/2004/12/09/1102182396504.html [verified 10 April 2011].
 Mitchell L. Time in a Bottle. The Age 2004; (6 April). Available at http://www.theage.com.au/articles/2004/04/05/1081017097958.html?oneclick=true [verified 10 April 2011].
 Walley T, Barton S. A purchaser perspective of managing new drugs: interferon beta as a case study. BMJ 1995; 311 796–9.
| 1:STN:280:DyaK28%2FmtFOmsA%3D%3D&md5=d654bb8c4a7b8361464a0432aac31cadCAS | 7580445PubMed |
 Daniels N, Teagarden JR, Sabin JE. An ethical template for pharmacy benefits. Health Aff (Millwood) 2003; 22 125–37.
| An ethical template for pharmacy benefits.CrossRef | 12528844PubMed |
 Marley J. Cost-effectiveness: the need to know. Australian Prescriber 1996; 19 58–9.
 Little JM. Money, morals and the conquest of mortality. Med J Aust 2003; 179 432–5.
| 14558869PubMed |
 McKie J, Shrimpton B, Hurworth R, Bell C, Richardson J. Who should be involved in health care decision making? A qualitative study. Health Care Anal 2008; 16 114–26.
| Who should be involved in health care decision making? A qualitative study.CrossRef | 18449805PubMed |
 Lee TH, Emanuel EJ. Tier 4 drugs and the fraying of the social compact. N Engl J Med 2008; 359 333–5.
| Tier 4 drugs and the fraying of the social compact.CrossRef | 1:CAS:528:DC%2BD1cXovFSqtL4%3D&md5=9e60d31299114fe4e75d5fb010d8c13cCAS | 18650510PubMed |