Medical Priorities – Memorandum for BUP Stockholm

Applicable to the Stockholm Health Care Services [Stockholms läns sjukvårdsområde]/Division of Psychiatry and Habilitation/Psychiatry/BUP Stockholm.

“Priority setting in healthcare is a continuously ongoing process in which there must always be a readiness to reconsider and to find new approaches and ways of working.”

(Swedish Ministry of Health and Social Affairs, 1996/60)

Background

When the Swedish Parliament decided on medical priorities, the decision was based on three ethical principles, which have an order of precedence:

The Human Dignity Principle

  • a fundamental principle of equal treatment and overarching guidance regarding what must not determine priorities.

The Principle of Need and Solidarity

  • those with greater needs take precedence over those with lesser needs.
  • patient benefit must be taken into account.
  • vulnerable groups must be safeguarded.
  • in the model: the severity of the health condition and the patient benefit of the intervention.

The Cost-Effectiveness Principle

  • subordinate to the two principles above.
  • interpreted to mean that those with more severe conditions may be treated with interventions that cost significantly more than those used for less severe illnesses, provided that effective interventions are available.
  • in the model: assessment of patient benefit and cost.

Government Bill 1996/97:60.

The mandate and responsibility of the healthcare professions to make these priorities have also been clarified:

“…it is the medical professions, healthcare providers and, ultimately, the healthcare authorities that bear the medical responsibility, as well as the responsibility for the priorities that must be made regarding how healthcare resources are to be used.”

(Swedish Ministry of Health and Social Affairs 2013/14, p. 36)

The individual patient has limited ability to demand specific interventions:

“…at the individual level, the patient shall be given the opportunity to choose between different treatment alternatives if these are consistent with science and proven experience and are reasonable in light of the current illness or injury and the cost of the alternatives.” 

(SFS 2014:821)

From the Parliamentary Decision to Practical Consequences

It soon became clear that there was a need to clarify how the actual work of priority setting should be carried out and that a clearer systematic approach was required. If this is not done, there is a risk that priority decisions fall to individual employees in a manner that may both increase ethical stress in difficult decision-making situations and reduce the quality of decisions, since they are based on individual interpretations.

This, in turn, increases the risk that the healthcare system makes different priority decisions at different levels without taking the ethical platform into account. When resource issues become the focus, this may, for example, lead to priority setting becoming synonymous with not offering care to certain patient groups.

The Priority Setting Centre and Support for Priority Setting

The Priority Setting Centre in Linköping [Prioriteringscentrum i Linköping] was therefore commissioned to develop support for healthcare organisations in conducting priority-setting work, and this is the work that BUP Stockholm has now undertaken.

The methodology involves identifying priority objects and ranking them on the basis of a number of factors. The methodology also takes into account the order of precedence among the ethical principles.

The steps are as follows:

  1. Determining the purpose and scope of the prioritisation/ranking.
  2. Identifying what is to be ranked (so-called priority objects).
  3. Assessing severity.
  4. Assessing patient benefit.
  5. Assessing cost in relation to patient benefit.
  6. Assessing the quality of the evidence supporting all assessments.
  7. Overall assessment and ranking.
  8. Presentation of the ranking and its underlying basis.

An important feature of the methodology is that it is priority objects that are to be prioritised, i.e. the combination of a health condition and an intervention. This clarification also entails particular challenges.

Purpose

Within BUP Stockholm, the scope was defined so that the priorities include the groups of disorders that BUP Stockholm is expected to assess and treat under its assignment to provide specialised child and adolescent psychiatric care, meaning the assessment and treatment of patients with psychiatric disorders.

The ranking is to be carried out for the individual priority objects, i.e.: health condition + intervention.

BUP Stockholm interpreted this as referring to the interventions described in its standardised, condition-specific clinical pathways (that already existed). During the work, however, it was possible to select subgroups based on the severity of the disorder. This selection was made on the basis of a clinical assessment by BUP Stockholm’s medically responsible senior consultants.

The purpose of this work is to support:

  • horizontal prioritisation (internal allocation of resources among different health conditions); and
  • decisions concerning rationing/efficiency measures for different priority objects within the organisation.

Priorities at the Organisational Level

The primary purpose is therefore to provide a basis for organisational decisions such as:

  • resource allocation;
  • the scope of specific care clinical pathways;
  • the range of different treatments offered;
  • planning of training programmes and their scope; and
  • forms of collaboration surrounding different patient groups.

At the unit level, a ranking list may be used to support decisions concerning, for example, discharge/termination of care or planning the number of visits required for follow-up of a particular pharmacological treatment. This is reflected, for example, in the overarching pharmacological guideline that BUP Stockholm develops and revises regularly.

Priorities at the Individual Level

At the level of the individual patient, the intention is that our general care process, the clinical pathways and individual assessments should serve as support and therefore carry significant weight.

The reason for this is that a ranking list does not have sufficient precision to support the judgements required for an individual patient. The vast majority of patients have a significant degree of comorbidity, which may make prioritisation based on condition-specific ranking difficult in individual cases.

In addition, there are other decisive factors/parameters, such as:

  • parental capacity;
  • family circumstances;
  • schooling;
  • exposure to violence; and
  • other relevant circumstances.

In summary, it cannot be emphasized enough that individual assessments based on clinical experience and competence must carry significant weight in individual cases. In this context, clear principles for prioritization may provide guidance, but must never alone be prescriptive in clinical decision-making.

Identification of Objects and Assessment of Severity and Patient Benefit

BUP Stockholm’s medically responsible senior consultants, together with the chief medical officer/senior consultant and the senior consultant responsible for care processes, were assigned to work on steps 2–4.

These steps are the most important in the process because the subsequent steps cannot upgrade an object; they can only lower its position in the ranking due to deficiencies in the evidence base or excessively high costs in relation to patient benefit.

The selection of priority objects is based on our most common conditions, or conditions that for other reasons need to be included. This includes severe, although rare, disorders which, if unidentified or untreated, entail a risk of serious or life-threatening consequences.

Examples of the latter within child and adolescent psychiatry are bipolar disorder and psychotic disorders.

Inpatient care, so to speak, prioritizes itself and would require an extensive and separate method of priority setting that is not linked in the same way to condition-specific interventions. Therefore, no ranking was made with regard to inpatient care per se.

The same applies to gender dysphoria and children aged 0–5 years and 11 months. If such children fall within one of the other care processes, such as ADHD, oppositional disorder or PTSD, they are included in the priority-setting work.

The reason why these groups have not otherwise been included is uncertainty regarding the evidence base and how the priority objects should be defined. Work is ongoing to review the available knowledge, and this may justify a later addition.

Cost in Relation to Patient Benefit and Assessment of the Quality of the Evidence Base

Cost in relation to patient benefit, and assessment of the quality of the evidence base, have been handled with great caution and using conservative assessments. They have therefore affected the ranking to a relatively limited extent.

Health economic reviews are rare within child and adolescent psychiatry and are also difficult to conduct. When researchers have been asked about these issues, they have likewise experienced considerable difficulty in making statements specifically regarding prioritisation in relation to the quality of the evidence base.

In practice, an assessment of the evidence base has been made through BUP Stockholm’s work with standardised, condition-specific clinical pathways. These are designed on the basis of the best available knowledge, including:

  • care programmes;
  • clinical guidelines;
  • guidelines from the National Board of Health and Welfare, where available; and
  • current research.

Process owners with knowledge of the relevant field, together with an overarching group of colleagues, have assessed what should and should not be included in the clinical pathways.

In this way, an assessment has been made, even though it did not take place directly in connection with the priority-setting work itself. The connection between the clinical pathways and the priority-setting process was established through an iterative process within the steering group for evidence-based medicine and the BUP Stockholm’s medically responsible senior consultants.

Overall Assessment and Ranking

Once the steps described above had been completed, an overall assessment was made.

In principle, limited patient benefit, high cost or a weak evidence base resulted in a certain reduction in the ranking, as shown in the attached table.

The Work Process So Far and Going Forward

The work on priorities effectively began as early as 2018, when a change in the section structure and subspecializing of the organization was initiated.

In connection with changes in the assignment, the need for clearer priorities became increasingly apparent. Consequently, BUP Stockholm’s management group initiated work in the autumn of 2023.

Since then, the issue has been discussed at meetings of unit managers, meetings of different professional groups, with the patient and family/significant-other council, and with researchers affiliated with BUP Stockholm.

There has throughout been an awareness of the difficulties involved in:

  • selecting the appropriate priority objects;
  • assessing the evidence base; and
  • assessing cost-effectiveness.

At the same time, the need for clearer prioritisation at the organisational level has been emphasised, not least in order to support individual employees.

This has contributed to the decision to carry out the work despite its obvious difficulties and limitations. The alternative of doing nothing would be worse.

Once again, the fundamental premise is that prioritisation is primarily about identifying which patient groups absolutely need to receive a greater share of our resources—in terms of the number of visits, staff competence development, investment in research, the number of treatment methods offered, and so forth—and how we can provide good, but more limited, interventions to patient groups given lower priority.

The Priority Setting Centre’s guidance emphasises the importance of transparency in priority decisions, so that different actors and stakeholders have the opportunity to provide comments and criticism.

It is therefore important that the ranking list be made available, with full awareness of its limitations.

It is also important that the list be viewed in the context that this introduction seeks to provide. The clinical pathways are revised regularly, which also means that the priorities need to be revised regularly.

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This text has been translated from Swedish with the assistance of an AI tool.

The original Swedish text can be downloaded here: Medicinska prioriteringar – PM för BUP Stockholm (docx) 

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