Integrating explicit priority setting criteria into shared decision-making in primary care

PhD project (3/4 yr research project leading to independent research at the doctorate level)

Amanda Owen-Smith, Joanna Coast, Tim Jones

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Many countries are moving to more explicit means of healthcare priority setting.1 In the UK, this includes the publication of clinical guidelines and recommendations for disinvestment by the National Institute of Health and Clinical Excellence (NICE) and the use of “prior approval” or “criteria based access” policies issued by local Clinical Commissioning Groups (CCGs). In addition, secondary care institutions may have their own policies relevant to accessing particular treatments or assessments, which might impact on primary care decision-making. Such policies are designed to both manage the referral behaviour of clinicians and make decision-making accountable to patients. However, there is limited research on the extent to which such policies actually modify referral behaviour, and how useful they are to clinicians and patients in practice. Clinicians use a number of techniques to manage rationing at the consultation level, but it is rarely addressed explicitly with patients.2,3

Aims & objectives

1. Review existing empirical evidence relating to healthcare rationing undertaken in primary care settings
2. Quantify the impact of restrictive policies on local CCG service provision.
3. Investigate how such restrictive policies are currently viewed by clinicians and patients and how they are discussed in primary care consultations.


The student will be expected to become familiar with the extensive theoretical and empirical literature on priority setting found within economics, ethics, sociology and medicine. A systematic review of all existing empirical studies looking at the process of healthcare rationing within primary care is likely to be undertaken before moving on to the primary fieldwork.
The empirical research will take a mixed quantitative and qualitative approach. Initial ideas for the quantitative work are to identify the extent of local restrictive policies through consulting the information available on CCG websites and examining the impact of these on referral behaviour and procedure rates through the interrogation of relevant NHS datasets.
Qualitative work will involve interviews with GPs and patients and conducting in-depth observations of clinical consultations. Sampling will be undertaken theoretically and analysis will be conducted using methods of constant comparison.


1Daniels N & Sabin J (2008) Accountability for reasonableness: an update. Br. Med. J., 337, p. 1850
2Maybin J & Klein R (2012) Thinking about Rationing. The King’s Fund, London.
3Owen-Smith A, Coast J, Donovan JL. (2015) How clinical rationing works in practice. Soc Sci Med, 147 288-295

Created on Nov. 28, 2016, 1:08 p.m.

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