1. Priority setting in Ontario's LHINs: Ethics & economics in action Jennifer Gibson, PhD University of Toronto Joint Centre for Bioethics Craig Mitton, PhD School of Population & Public Health, University of British Columbia On behalf of the LHIN Priority Setting Working Group

2. Session Goal & Objectives  Goal: To share experience with developing a priority setting framework for Ontario’s Local Health Integration Networks (LHINs)  Objectives: - To introduce an interdisciplinary priority setting framework based on ethical and economic principles - To describe its implementation & evaluation in Ontario’s LHINs - To identify key lessons learned

3. Guiding Principles  Economic principles of ‘value for money’ - What priorities should be set to optimize health benefits & achieve health system goals in resource constraints?  Ethical principles of fair process - How should these priorities be set to ensure legitimacy and fairness in the eyes of affected stakeholders?

4. *Gibson, Martin & Singer. SSM 2005; 61: 2355–2362. Priority Setting Approaches ECONOMICS Program budgeting & marginal analysis (PBMA) ETHICS Accountability for reasonableness (A4R) REVISION EMPOWERMENT* ENFORCEMENT RELEVANCE PUBLICITYFAIRPROCESSES OPTIMAL BENEFITS

5. Gibson, Mitton, et al., JHSRP 2006; 11(1): 32-37. Interdisciplinary Approach

6. LHIN Priority Setting Project

7. Background: Ontario’s LHINs  Launched in 2005  No direct service provision - responsible for planning, coordinating, & funding services  Gradual devolution of accountability from ministry to LHINs (early 2007)

8. Project Goal  To develop a priority setting framework that would help LHINs: − Align resources strategically with system goals and population needs − Facilitate constructive stakeholder engagement − Make publicly defensible decisions based on available evidence and community values − Demonstrate public accountability for finite health resources

9. Project Overview Feb-Mar ‘09Nov ’08…Feb ’08…Oct ’07… PHASE IVPHASE IIIPHASE IIPHASE I Development Implementation LHIN Pilots (3) Refinement Evaluation

10. Phase I. Development 1a. Criteria: Link decisions explicitly to local/system strategic plans, population needs, system values, & performance goals STRATEGIC FIT LHIN and MOH strategic plans; Provider system role (mandate & capacity) POPULATION HEALTH Health status, prevalence, health promotion/ prevention SYSTEM VALUES Client-focus, partnerships, community engagement, innovation, equity, operational efficiency SYSTEM PERFORMANCE Access, quality, sustainability, integration

11. 2 3 4 1 55 4 3 2 1 13 521 Step 1. Compliance Screen  Legal/regulatory  Contractual Agreements (e.g., AAs) Step 2. Evaluation (15 criteria) Step 3. Cost-Benefit Analysis Step 4. System Readiness Screen  LHIN capacity  Interdependency  Risk  Health system impact 1b. Criteria-based Decision Tool: Rate/rank funding options systematically to ensure consistent rationale across decisions

12. 2. Processes: Establish overall legitimacy and fairness of decisions, including constructive stakeholder involvement Gibson, et al., Healthcare Quarterly 2005, 8(2); Mitton & Donaldson, The Priority Setting Toolkit, BMJ Books, 2004.

13. Phase II. Implementation  Framework piloted in 3 LHINs  Funds available for strategic investment: $800K - $2M  Success rate: ~10%

14. Phase III: Evaluation  On-line Survey of health service providers (n = 110)  Interviews with LHIN Staff (~30) across all three pilot sites  Analysis: - Descriptive analysis - survey data (closed) - Thematic analysis - interviews and survey data (open-ended) - Evaluation - A4R as a conceptual framework

15. Key Lessons Learned

16. Key Findings  Overall, framework perceived to be helpful. Value of framework  Systematic & disciplined approach  Greater consistency and less subjectivity in DM  Credible basis for explaining decisions  Basis for constructive dialogue about scarcity internally and externally  Good preparation for ‘high stakes’ re-allocation (trust-building)

17. Key Findings  Contextual realities present challenges for implementation Challenges  Changing ministry directions  Tight timelines  Inconsistent availability of data  “Promise of benefit” vs. real benefit – need for performance monitoring  Uneven playing field due to different capacities of provider organizations (small vs. large)

18. What counts as fair?  Funding success Unfunded – somewhat more likely to think process was not fair (35% vs. 21%)

19. What counts as fair?  Transparency, transparency, transparency FAIRNOT FAIR LHIN’s goals, criteria, & funding processes were communicated clearly. 85% Agreed 60% Disagreed LHIN’s funding rationales were communicated clearly. 52% Agreed 89% Disagreed

20. Concluding comments  Trust is more not less important during a time of system transformation and change.  Incremental implementation and open evaluation may be key tools to advance trust within the system.  Interdisciplinary project is unfinished - time to engage organizational change theory.

21. Priority setting in Ontario's LHINs: Ethics & economics in action jennifer.gibson@utoronto.ca craig.mitton@ubc.ca

22. Questions? Comments?