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P Mullen, P Spurgeon. Radcliffe Medical Press, 2000, £24.50, pp 168. ISBN 185775297X
As its title suggests this book's main area of inquiry is the rationale for, and methodology of, public involvement in priority setting. Mullen and Spurgeon set out to evaluate a number of assumptions and hard issues in priority setting. In doing so they have a produced a volume that is both a useful introduction to this area and a worthy piece of research on an important theme.
They begin by contextualising the debate about prioritisation within the recent history of health system reform in the UK and other nations. This move enables them to give an analysis of considerable scope. They are not just interested in rationing and public involvement but also in questions about the level to which the UK National Health Service (NHS) ought to be publicly funded. Given the frequently stated assumption that rationing is inevitable it is very refreshing to read a book that grapples with the difficult, more primary question of whether rationing itself is in fact necessary.
They note that reform processes and initiatives in the health system have served to focus attention on the need for priority setting but that there is a need to evaluate carefully the basis of this need. The present level of funding that the NHS receives is a matter of choice and not simply a result of economic necessity, as is frequently implied. They suggest that we should think carefully about the inevitability of rationing and our inability to pay and instead work out how to provide treatments that are of undisputed efficacy.
In chapter three they examine the basis for public involvement in priority setting. Given that many would think that public involvement in the setting of priorities is a good thing they ask the pertinent question, whether such involvement would result in the optimum set of priorities and consider whether it may risk a “dictatorship of the uninformed” (34). Other key difficulties addressed are the problems of finding a group that can be considered representative.
In chapter four they survey the traditional approaches to priority setting. This includes a detailed section on QALYs and the standard objections to them. This chapter contains an interesting section on how the rule of rescue can conflict with the maximisation of health care gain that is associated with QALYs (44–45). They cite the Jaymee Bowen case as an example of the depth of feeling that can be evoked when the rule of rescue conflicts with the maximisation of health care benefit.
Their sixth chapter considers in some depth empirical methods that can be used to elicit the values of the public about priority setting. They present a broad range of possible methods in a way that makes them useful, not only for ascertaining views about prioritisation but also for gaining information about other empirical questions within medical ethics.
Given the amount of literature on this topic it is inevitable that some issues are dealt with in a fairly summary fashion, but when they do this the authors make reference to the wider literature.
All those interested in prioritisation and the NHS ought to read this book. It's likely to be of special interest to those making prioritisation decisions at all levels.