Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Dangerous findings
- Mike Tremblay (3 April 1999)
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Prevention goes unappreciated
- William J McCarthy (7 April 1999)
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Where are the data?
- Barbara Hanratty, Debbie Lawlor (14 April 1999)
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Priority setting in a district
- Shalini Pooransingh (15 May 1999)
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Mike Tremblay, Director, Eden Communications Ltd, public service broadcasting UK
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The specific finding that the public, after discussion, would defer to health managers is an very dangerous finding. I am very nervous about this study particularly to ensure that a full range of choices were presented to the respondents, how was the discussion framed, etc. Certainly, I would be very nervous about taking these findings forward without a better understanding of the implications. However, it does raise the issue of how to increase public understanding and awareness of health issues. I would not want wider public consultation simply to provide further evidence that health managers are doing the right thing (even if they are). We know how the public's views can be manipulated through selective information dissemination and would hope that the public views would represent a powerful axis to the prevailing thinking and approaches, and not just a function of it. |
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William J McCarthy, Adj. Associate Professor UCLA Division of Cancer Prevention
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Dear Editor:
The findings of Dolan and associates, if generalizable, suggest that the public would prefer to reduce investment in the prevention of disease relative to its treatment. Significant numbers of respondents reported wanting to decrease current health expenditures for people who drink heavily, who smoke, who don't exercise, who eat poorly and who use illegal drugs. When given time to discuss and reflect on these views, there was perceptible movement of respondents' judgments away from volunteering to disinvest limited health care resources in treating people whose lifestyle choices put them at higher risk of disease, but the overall sentiment remained negative. No more than 5% of respondents were willing to invest in more treatment opportunities for such patients, after deliberating health priorities.
This is unfortunate, inasmuch as scientific research shows that earlier and more frequent intervention with people evincing poor lifestyle choices can yield cost-effective health outcomes (e.g.,Rigotti et al., 1996; Wheat et al., 1996). It is not clear that investing the same resources in treating the natural consequences of aging will yield as much benefit. I thought that the movement toward evidence-based medicine implicitly denigrated the ability of physicians, as informed as they are, to make health care decisions of maximal benefit to society. Insofar as most patients are less informed than their physicians, they should be even less able to make informed judgments, even after attending two discussion group meetings to deliberate how to prioritize the allocation of treatment resources. I applaud the impulse to include consumer and taxpayer input into establishing treatment priorities, but the weight given such judgments needs to be subordinated to the societal "better bet" of scientific judgment, when sufficient scientific evidence is available. William J. McCarthy, Ph.D. References. Rigotti, NA; Pasternak, RC. Cigarette smoking and coronary heart disease: risks and management. Cardiology Clinics, 1996;14:51-68. Wheat, G; Carter, A; McAfee, T; Thompson, RS; Gayman, J; Meuchel, K. Addressing a neglected coronary heart disease risk factor in an HMO: exercise counseling and fitness testing at group health cooperative. Hmo Practice, 1996;10:131-6. |
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Barbara Hanratty, Visiting Lecturers in Public Health Medicine Nuffield Institute for Health, Debbie Lawlor
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Dolan et al conclude that people's views on setting priorities differ systematically when they have been given the opportunity to discuss and deliberate, yet they present data which demonstrate the stability of the public's opinions. After discussion, more than half of the respondents (52%) did not change their minds about who should be involved in priority setting. A further 40% shifted only one point on a five-point scale, which was aggregated to three points, suggesting that the scale discriminated poorly between different preferences. When the participants considered which groups should be proritised, 63% did not change their minds, and overall, only two groups were prioritised differently the second time. The assumption that respondents to questionnaire surveys fail to consider their replies carefully underlies this study, though we are not aware of any evidence to support this. The authors also present no data to support the implication that the second, more considered responses have greater validity. Academic training may affirm the belief that decisions should be pondered over, but an instinctive view on what is right and wrong may reflect the values of society, and be appropriate for priority setting. The theoretical framework used for their sample selection is not presented in the paper, though they do give a description of the group in table one, including their political allegiance. However, there is no explanation of why these characteristics were important to the study. Others are not included, but seem to us to be relevant, for example occupation, family or personal history of handicap or chronic disease. Data from the focus groups should have been presented, as otherwise we cannot know if the content of the discussion influenced the small number of people who changed their minds, and the results loose both validity and generalisability. The possibility of bias being introduced by the facilitator has also not been addressed, and the participants understanding of some of the terms used was not explored. For example, in the second survey, more participants wanted to discriminate against people who were 'responsible for their own illnesses', but fewer people would penalise people who drank alcohol or smoked. We feel that the results do not justify the conclusions, and the omission of the core of the results brings into question the external and internal validity of the paper. We applaud the BMJ's willingness to publish qualitative research such as focus groups, but should we await the data from this study in another journal? |
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Shalini Pooransingh
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Dolan et al stated that the public's views about setting priorities in health care are different when they have been given an opportunity to discuss the issues. On a similar note, in developing the first draft of our Health Improvement Programme (HImP) in Walsall we consulted the public including users and carers and professionals in our approach to ensure that local perspectives were taken into account. Four focus groups were held in our four primary care group ( PCG) areas in Oct 1998, aiming to bring together a wide cross section of persons in keeping with HSC 1998/167, representing statutory and voluntary organisations, the private sector, local communities and individuals. Among those who attended, 303 were from professional backgrounds, with 138 persons representing the public. Choosing to hold the focus groups in PCG areas was not a chance occurrence. We knew the role of primary care and PCGs would be a major one in the development and implementation of the HImP. At the start of each focus group meeting, participants were assigned to table groups consisting of eight persons ensuring a good mix of backgrounds. Participants were given a basic introduction to HImP, Health Action Zones (Walsall has been designated one) and PCGs and allowed an opportunity for questions. They were then asked to consider the relative importance of the national and Walsall priorities as well as local issues pertinent to each PCG area and to rank the national objectives as well as two Walsall priorities and one local one. Following considerable deliberations the participants were able to identify key priorities for Walsall. Interestingly, across all four focus groups the Walsall wide objectives were prioritised in the same way: drugs (including smoking and alcohol) as top priority followed by disability support for carers and users and teenage pregnancy in that order. In relation to national priorities, mental health was the overwhelming choice. These objectives were incorporated into our draft HImP with drugs and teenage pregnancy in the section on 'addressing health inequalities' with disability support in the chapter headed 'responding to national and local priorities'. The overall view in Walsall was that the process was a success as it brought together a large number of people to deliberate on priorities. The participants stated that the workshops had given them an opportunity to participate and express their views. In this era of change within the NHS with particular reference to primary care and PCGs and their role in the development and implementation of the HImP for their district, it seems that public participation and user involvement is here to stay. Jordan et al stated that it is questionable whether GPs can act as proxies for patient need because of the differing perceptions of doctors and patients as well as the issue of need versus demand. The danger of GPs assuming needs of the community based on their practice experience, coupled with the conflict surrounding GPs' views of individual needs superseding those of the community, show that there is a role for community involvement. GPs cannot expect or be expected to know the needs of the community, thus the value of local consultation in identifying unidentified need. Dr Shalini Pooransingh Specialist Registrar in Public Health Medicine Dr Sam Ramaiah Director of Public Health Medicine 1 Dolan P , Cookson R, Ferguson B , Effect of discussion and deliberation on the public's views of priority setting in health care : focus group study British Medical Journal 1999;318:916-9 2 Jordan J, Dowswell T, Harrison S, Lilford RJ, Mort M. Whose priorities in listening to patients and professionals. In:Wright J, ed Health Needs Assessment in Practice London BMJ books 1998: 60-67 |
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