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Ethical Issues

Resource Allocation

Priorities Forums

Clinical ethics committees may be asked for advice on resource allocation issues at the level of individual patient care or in relation to setting priorities within an acute trust. In the UK, decisions about distributing resources for larger communities and populations lie within the remit of PCTs or health authorities. Many PCTs either have, or are considering developing, a committee or forum to advise on commissioning priorities for the PCT. Some of these priorities forums were originally developed within area health authorities prior to the reorganisation of the NHS in 2003. PCTs also have committees or panels that consider requests for individual patient treatments that fall outside the broad range of services routinely commissioned by the PCT. Some priorities forums have developed an ethical framework to inform their decision-making. The use of such a framework helps to achieve consistency and transparency of decision-making.

An example of a priorities forum that has developed an ethical framework is the forum first established within Oxfordshire Area Health Authority, and now hosted by Oxfordshire PCTs.

The ethical framework of the Oxfordshire Priorities Forum is structured around three main components:

  • effectiveness of treatment - the extent to which the healthcare intervention achieves the desired effect - and value of a particular treatment - a judgement on how valuable that effect is for the relevant individual, relative to the value of other treatments
  • equity - people in similar situations should be treated similarly. There should be no discrimination on grounds of employment status, family circumstances, lifestyle, learning disability, age, race, sex etc.
  • patient choice - patients can choose between treatments of similar efficiency.

T.Hope, N. Hicks, D.J.M. Reynolds, R. Crisp, S. Griffiths, Rationing and the health authority, British Medical Journal, Oct 17, 1998.

The need for health authorities (or PCTs) to have a framework within which to make decisions about treatment priorities was recognised by the Court of Appeal in 1999.

R v North West Lancashire HA ex p A, D and G (1999) 53 BMLR 148, [2000] 1 WLR 977

The Court of Appeal said that a decision regarding the provision of treatment must be taken within a proper framework.
Although it is appropriate for a Health Authority to have a policy for establishing certain priorities in funding different treatments, in establishing priorities - comparing the respective needs of patients suffering from different illnesses and determining the respective strengths of their claims to treatment - it is vital for the Health Authority to:
accurately assess the nature and seriousness of each type of illness
determine the effectiveness of various forms of treatment for it, AND
give proper effect to that assessment and that determination in the formulation and individual application of its policy