Prioritizing investment in public health and health equity: what can commissioners do?

OBJECTIVES: To explore commissioners' views on prioritizing for investment in health. This study reviewed: methods for decision support; their relevance for prioritizing health and health equity in principle; and their adoption by decision makers in practice.
METHODS: Decision makers' views were sought through semi-structured interviews and an online survey, and prioritization tools were reviewed. Interviews were held in 2008-2009 with a subsample followed up in 2009-2010. In late 2009, a national online survey was sent to 508 individuals across 146 primary care trusts (PCTs). The two phases of the interviews comprised 52 and 17 participants, respectively. Responses to the national survey were received from 138 decision makers in 95 (65%) PCTs. Prioritization tools were identified through interviews and the survey as above, a rapid review of literature and in consultation with health economists. A grounded theory approach was adopted for the qualitative interview analysis.
RESULTS: Although most PCTs used a prioritization framework, few of the tools identified in this review were used by public health commissioners. This was partly a consequence of limitations of priority-setting tools in the context of public health investment, and partly a lack of relevant skills and data. Tensions in relation to developing strategies for disinvestment and in prioritizing a long-term public health agenda in a context of economic austerity were evident.
CONCLUSIONS: The context for decision making appears to be more important than the deployment of specific tools and techniques. Commissioners need to recognize the limitations of priority-setting tools, but also know how to apply them to help maximize health gain and health equity over the longer term. Decision-support tools should be developed in collaboration with public health commissioners to ensure relevance and practicality of use.