Managing scarcity :understanding and developing the use of economics in healthcare commissioning

Abstract

In the UK, healthcare resources are scarce and insufficient to meet all claims on them. Such scarcity has to be managed. Economics provides a set of principles for managing scarcity. However, economic methods have had limited impact on managing scarcity in healthcare decision-making. This thesis argues that economics must fit alongside the pragmatic necessities of everyday decision-making. The focus of this research was to work within an NHS organisation to consider how decision-making was organised and explore the potential for using health economics, using programme budgeting and marginal analysis (PBMA) as a vehicle to study how health economics can be informed by, and inform, the management of scarce resources in the 'real world'. The research was conducted using a participatory action research (PAR) framework to study PBMA in three phases: before, during, and after its introduction into the organisation. Qualitative interview, observation, and focus groups methods were used to examine the organisational context prior to the implementation of PBMA, record the implementation of PBMA, and reflect on the implementation of PBMA. Through thematic qualitative analyses of these data sources, this thesis presents a rich description of the decision-making context and the inherent constraints; an account of how PBMA was applied; and the challenges of implementing PBMA. These findings indicate that economics provides a set of principles for managing scarcity that are embedded in the discourses surrounding PCT commissioning. However, these principles are rarely borne out in the decision-making processes. Both strengths and weaknesses in the PBMA method, and barriers and facilitators in the application of PBMA were identified. More research is needed to integrate PBMA into the organisational culture, something that may come with further iterations of the PAR framework.