In 2003, the politicians in one county council in Sweden, The County Council of Östergötland, decided that certain health-care services would no longer be covered within the publicly financed health care. This decision was unique since both the content of it and the decision-making process was transparent. The media attention was extensive and the decision, which media called the "black list", was debated at both local and national levels. The experience of the transparent decision and its aftermath frightened many politicians – even though the authorities, medical professionals and other organizations welcomed the initiative.
Since the decision was made in 2003, The County Council of Östergötland has continued its attempt to work with transparent and systematic priority setting, and has also further developed its procedure for priority setting on the political level. The National Centre for Priority Setting in Health Care has followed Östergötlands work with priority setting in health care since 2003; this is the fourth report on the subject. Based on archive data and interviews with politicians, public officials and health-care executives, we present the results of a study that on one hand aimed to describe the 2006 priority-setting procedure in the county council, and on the other hand aimed to highlight possible differences in the priority-setting procedure during the years 2003-2006. Special focus was made to study expectations, goals, changes in procedure and in the practical approach. This includes the informants’ view of roles, how arguments and line of reasoning was presented, how well the notion of priority setting was established among various actors and the informants’ perception of transparency.
The opportunity to study Östergötlands work with priority setting during four years has also given us the possibility to reflect on a characterization of a political priority-setting procedure. The procedure of setting priorities is a continuous activity within the county council and during the past four years the political priority-setting procedure has improved gradually in many ways. Vertical ranking-lists are now established for more disease groups than before. In recent years, more medical professional groups are involved in the construction of ranking lists and to report the descriptions of consequences if rationalizing. Reasons and justifications for the decisions have not always existed during the studied years, but have been gradually developed.
In addition, examples of areas where informants consider there have been improvements are:
• A clearer procedure and a clearer division of responsibility.
• A more realistic timetable including better scheduled time for discussion and processing information needed for the decision making (facts and knowledge).
• Better communication between the politicians and the medical professionals, mostly through public officials, who are perceived to have a central role as translators, mediators and being the driving force in the priority-setting process.
Despite all the positive trends towards a transparent procedure for political priorities, there are certain areas in need of further improvement, such as:
• How to spread knowledge throughout the organization about reasons and rationales behind the priority-setting procedure and also how decisions about resource allocation are carried out.
• How to clarify the roles and division of responsibility including which decision might be appropriate to bring up to the political level.
• How to balance information from the vertical ranking-lists and the descriptions of consequences with political values and with information from other sources.
• How to accomplish and strengthen internal support.
• How to encourage the external understanding for priority setting and how to publicly present the reasons and justifications behind decisions.
• How to monitor the collaboration methods, decisions and implementation of decisions.
Furthermore, from the experience of the work in Östergötland we found that a procedure for priority setting on the political level is characterized by the following six different phases:
1. The grounding phase (directives, conditions, roles)
2. The fact finding phase (gathering relevant information, i.e. facts and knowledge)
3. The dialogue phase (the internal dialogue)
4. The decision-making phase (making decisions including presenting justifications)
5. The publicity phase (activities, internal and external support and understanding)
6. The evaluation phase (assessment of procedure and results).
In the report we give a few brief thoughts on each of these phases, and discuss lessons learned and essential components to consider when planning for a procedure for priority setting on the political level.
Finally, we note that there is a consensus among leading politicians, public officials and healthcare executives to continue the work with transparent priority setting on the political level. However, it is still uncertain how this practically should be carried out. We do not believe that we have managed to detect and explain every aspect of how an approach to set priorities on the political level might be carried out, but hopefully our reflections can serve as a starting point for further work and further development.