By P. Mullen and P. Spurgeon. Radcliffe Medical Press, Abingdon, UK, 2000, £24.50, 168pp
Priority setting and the public challenges the standard interpretation that rationing in health‐care is inevitable and it is, thus, to be welcomed in widening the currently limited debate. The authors begin by considering the impetus for the explosion of interest in priority setting and rationing that occurred during the 1990s, locating its origins in the development of the internal market as well as general cultural changes such as the increasing importance attributed to evidence‐based medicine. They continue by examining the evidence for the existence of rationing (chapter 2) before switching their emphasis towards the public, with discussion of various bases for public involvement in priority setting (chapters 3 and 4), methods for obtaining public views (chapter 5), methods for eliciting values (chapter 6) and actual experience in obtaining public views (chapter 7). The final chapter draws together the work by looking at the experience of priority setting and public involvement in New Zealand.
The book provides a refreshing interpretation of the familiar subject of priority setting in health‐care. There is an emphasis on looking for evidence of rationing, as opposed to asserting its existence – atypical but certainly to be welcomed – with the authors suggesting that the ‘macho’ emphasis on tough decisions increases (unhelpfully) the emotion involved in debate and distracts from the possibility of alleviating shortage by increasing the resources available. The authors describe their own position, which sets the tone for the book as a whole, as one in which ‘not all priority setting in health‐care is associated with or necessarily leads to the denial currently associated with the term “rationing”’ (p.9).
The desire to find evidence for the existence of rationing is mirrored in the later examination of evidence for the easy assertion that public participation is to be welcomed on the basis of increased democracy. In considering this evidence, the authors question whether a sample of individuals making decisions on behalf of a wider group does, in fact, increase the legitimacy of decision‐making.
These challenges to the more established view that priority setting is inevitable, should be explicit and should involve the public, are one of the most interesting facets of the book, but in its less theoretical aspects it also has much to offer. The description of methods for obtaining public views does not differ significantly from the sorts of sections that can be found in other books on priority setting, but the subsequent chapter on eliciting values is more innovative. It describes methods from a number of disciplines and compares them in terms of the explicitness of the approach, the implications of aggregation, whether the method imposes constraints on respondents, and transparency and ease of use. This section (with chapter 7 and the associated appendix) will be extremely useful for those wanting an overview of value elicitation techniques from outside their own discipline.
The book occasionally suffers from lack of structure and sign‐posting, leaving readers having to work out for themselves quite how chapters and sections both differ from, and relate to, one another. It would also have benefited from more in the way of the authors’ own conclusions. Apart from these caveats, however, the book is well written and offers an original analysis of priority setting in health‐care. It will also provide a useful source of references for health‐workers or researchers engaged in eliciting public views. (Indeed, this appears to be one of the purposes of the authors in writing the book, given their concerns about current and extensive ‘reinvention of the wheel’.) For anyone working in this area, Priority setting and the public is well worth reading.