Comment / Can the NHS live without priorities?

Sometimes, in order to get out of a rut, we have to challenge certain cherished assumptions and ask new questions.

Take priorities, for instance. Without setting priorities, including investment priorities, our efforts would be dissipated and ineffective, right? Not necessarily. Experience has brought me to the opposite view.

To be pedantic, there can only be one priority at a time, so to refer to priorities in the plural is an oxymoron. And the trouble with choosing priorities is that they instantly relegate everything else.

As a director of public health I feel I have 780,000 priorities because that's how many people live in my patch. Each of them should have equal opportunity to live life to the fullest. But that's not a priority, that's a value. We should ditch priorities and concentrate on values. Values are inclusive and enabling, but priorities exclude and constrain.

Choosing and ranking priorities can become divisive because of the trade-offs between financial priorities, performance priorities and health gain priorities. Then there is 'mission creep'. In the public's mind, priorities become expectations, and expectations become promises. Any perceived shortfall becomes a broken promise.

Worse still, priorities get converted to targets and expressed in numerical values, whereas most performance is qualitative. Outcomes are judged as pass or fail, whereas most performance is part of a continuum. Then along with targets comes the whole burden of inspection, regulation, bureaucracy, short time horizons and misleading league tables. Having intended to give focus, we end up with the opposite - disjointedness, demotivation and expenditure out of proportion to the benefit. 

Priorities cannot be assessed in advance, only in retrospect. What did the organisation actually do when
the key job couldn't be filled
the bad weather struck
the latest policy initiative was launched?

Such challenges expose the true priorities.

So what instead? We should start by accepting that health improvement and healthcare are complex and cannot be reduced to a few priorities, targets or soundbites. A promising way forward is programme budgeting and marginal analysis, recently re-invented by the Department of Health and endorsed as a World Class Commissioning competency.

Although the data on costs and outcomes needs more refinement, this is a systematic summary of where PCTs spend their resources in 23 comprehensive programmes of care, backed up by activity and outcome data.  Some PCTs already use it to frame commissioning intentions and performance.

Using a programme budgeting approach, a local health system can pose a rich set of questions about each health programme in turn, such as: can we show that we are improving health and reducing inequality?  What return do we see on that investment in terms of activity and outcome? How do we compare with similar PCTs? How will we redeploy the programmes' resources, this year and next? What do the public and providers think of our analysis of the position and our plans?

In this way every patient, manager and clinician can see their place in the scheme and the directors of finance, commissioning and public health are united in a common purpose.
So let's do away with priorities and targets, and get back to values and a comprehensive, inclusive approach. That's my priority.

Dr Peter Brambleby is director of public health, North Yorkshire and York PCT and North Yorkshire County Council