NHS Bristol, North Somerset and South Gloucestershire CCG commissioned an ethical framework overview to explore whether incorporating ethical principles into their commissioning processes would ultimately enable better decision-making on spending and resource allocation.
Arden & GEM’s Solutions for Public Health team supported the CCG’s Executive team to develop and implement a new framework of commissioning principles which enabled them to make fair, transparent and consistent policy decisions which were more transparent and acceptable to their population.
The challenge
NHS Bristol, North Somerset and South Gloucestershire CCG is responsible for shaping healthcare services for the more than one million people.
Solutions for Public Health (SPH) was commissioned to help the CCG integrate ethical principles into their decision-making in order to improve resource allocation and value. The rationale was based on existing theories and experience, exploring these with CCG staff, and facilitating frank and open discussion as to whether this would be a useful approach. The objectives set out at the outset were to:
- Assess the CCG's need for an ethical framework
- Introduce basic ethical theories
- Consider case studies
- Explore and discuss ethical values and principles
- Demonstrate Judicial Review considerations.
Our approach
SPH took a six-stage approach, leading the CCG through a practical pathway to developing their own perspectives and exploring how existing decision-making processes might be improved.
1. Exploring who might consider evidence and make recommendations to the CCG
We mapped out the local commissioning landscape in collaboration with CCG staff. This identified 10 separate groups who were provided, by the CCG, with evidence-based material to inform commissioning and service provision decisions. We worked through these in turn, following the process through to policy development and final decision-making. This enabled us to identify early on where and how ethical principles may be used to underpin and consolidate existing processes.
2. Defining and contextualising prioritisation
We used the commissioning map to identify points at which due process was particularly important, and where the CCG might be held accountable for transparency and robust consideration of an ethical framework when shaping policy. This resulted in a detailed process map, beginning with a topic request, and following the priority-setting process forensically through to commissioning decision.
3. Discussing differences between commissioning for populations and individuals
We held open discussions with the CCG regarding their perception of differences between populations and individuals when making commissioning decisions.
A key comparison was made between complex and potentially high risk/high profile Individual Funding Requests (IFRs) and the broader population commissioning process. Our highly experienced IFR team deconstructed decision making into the ’3 Rs‘ – Rationale, Reasonable, Reproducible – demonstrating how placing decisions into this ethical context can both maximise the robustness of the process and reduce anxiety in staff tasked with making final decisions.
4. Adopting/constructing an ethical framework that was both pragmatic and fit for purpose
We guided the CCG through key ethical frameworks used and accepted in contemporary decision-making and that cross over into the legal frameworks that underpin medicolegal practice and case law. Utilitarianism, Needs Theory, Casuistry, Principle-based Theory and Opportunity Maximisation were all explored to help staff consider how their own value judgments and those of the wider population may vary between a focus on maximisation of overall population and a desire to protect the rights of the individual to access effective treatments where they exist.
5. Working through case studies
We worked through six scenarios with CCG staff, placing patient need in different circumstances of need and risk. We encouraged staff to state both their decision and rationale, recording their thoughts in a framework tool.
6. Walking through Judicial Review
SPH has real world experience of its processes being taken to Judicial Review, considered to be the final destination for contentious and high-risk decision- making. We consulted with legal experts to help the CCG understand the medicolegal context, including relevant case law, and how to relate their decisions to key items of Human Rights legislation, generally the underpinning framework in care-related Judicial Review.
We explained in detail the meaning of a judgement and how this can be challenged and grounds for appeal. Ultimately, we emphasised how the Judicial Review is focused on the process followed by the CCG, rather than the actual commissioning decision they took.
Outcomes
Through collaboration and a spirit of openness and joint learning, we supported the CCG’s Executive team to develop and adopt a new framework of commissioning principles which enabled them to make fair, transparent and consistent policy decisions for their population.
We designed and led two highly interactive workshops for the Governing Body and the Senior Commissioning team covering the following topics:
- Introducing the theory behind ethical principles
- Understanding the extent to which principles affect decisions and the consequences for patients
- Exploring and debating the impact of ethical principles using a range of commissioning scenarios
- Understanding legal requirements and duties for the CCG (with the help of David Lock QC)
- Understanding the key components required to make a satisfying decision.
As our work on the project concluded, the CCG was happy to independently take the recommendations forward toward full adoption and implementation.