Social Science & Medicine 98 (2013) 162e168

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Using programme budgeting and marginal analysis (PBMA) to set

priorities: Reections from a qualitative assessment in an English
Primary Care Trust
Elizabeth Goodwin a, *, Emma J. Frew b
a
b

NHS Plymouth (Plymouth Primary Care Trust), Building One, Brest Road, Plymouth PL6 5QZ, UK
Health Economics Unit, Public Health Building, University of Birmingham, B15 2TT, UK

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 2 October 2013

In England from 2002 to 2013, Primary Care Trusts (PCTs) were responsible for commissioning
healthcare for their local populations. The NHS has recently undergone rapid organisational change
whereby clinicians have assumed responsibility for local commissioning decisions. This change in
commissioning arrangements alongside the current nancial pressures facing the NHS provides an
impetus for considering the use of technical prioritisation methods to enable the identication of
savings without having a detrimental effect on the health of the population. This paper reports on the
design and implementation of a technical prioritisation method termed PBMA applied within NHS
Plymouth, an English PCT responsible for commissioning services for a population of approximately
270,000. We evaluated the effectiveness of the process, the extent to which it was appropriate for local
healthcare commissioning and whether it identied budget savings. Using qualitative research methodology, we found the process produced clear strategic and operational priorities for 2010/11, providing
staff with focus and structure, and delivered a substantial planned reduction in hospital activity levels.
Participants expressed satisfaction with the process. NHS Plymouth adhered to the PBMA process,
although concerns were raised about the evidence for some priorities, decibel rationing, and a lack of
robust challenge at priority-setting meetings. Further work is required to enhance participants understanding of marginal analysis. Participants highlighted several external benets, particularly in
terms of cultural change, and felt the process should encompass the whole local health and social care
community. This evaluation indicates that the prioritisation method was effective in producing priorities for NHS Plymouth, and that PBMA provides an appropriate method for allocating resources at a
local level. In order for PBMA to identify savings, cultural and structural barriers to disinvestment must
be addressed. These ndings will interest other healthcare commissioners in developing their own
approaches to priority-setting.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Programme budgeting
Marginal analysis
Priority-setting
Resource allocation
Commissioning

Introduction
The recent changes to the NHS in England, whereby clinicians
have assumed responsibility for local commissioning decisions,
provide an opportunity to improve the methods used for allocating
healthcare resources. Prior to this Primary Care Trusts (PCTs)
commissioned healthcare for their local populations. PCTs traditionally based resource allocation decisions on historical data,

* Corresponding author. Present address: Health Economics Group, University of

Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, UK.
Fax: 44 (0) 1392 421009.
E-mail address: e.goodwin@exeter.ac.uk (E. Goodwin).
0277-9536/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2013.09.020

adjusted for anticipated demographic and technological changes,

and policy objectives. These historical or political rationing
methods can fail to maximise health gain for the available budget,
and this limitation has given rise to the development of more sophisticated technical methods (Eddama & Coast, 2009). Such
methods are all the more salient given the current nancial pressures facing the NHS: a technical approach to prioritisation can
enable the identication of savings that minimise detrimental
impacts on patients while allowing continuing improvements in
services (Mitton, Patten, Waldner, & Donaldson, 2003). A structured
process can also provide a useful framework for clinical leadership
in commissioning.
One technical approach to resource allocation is programme
budgeting and marginal analysis (PBMA), which has been applied

E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

to healthcare in over 80 studies worldwide (Wilson, Peacock, &

Ruta, 2009). In recent years a number of initiatives have aimed to
promote and facilitate the implementation of PBMA based approaches in the NHS, including the annual Programme Budgeting
benchmarking tool, which enables local commissioners to compare
their expenditure on 23 health programmes with national or
comparator group averages (Department of Health, 2011), the Right
Care programme, which forms part of the NHS Quality, Innovation,
Productivity, and Prevention (QIPP) agenda, and a pilot study of
PBMA in three regions, which was supported by the NHS Institute
for Innovation and Improvement (Kemp et al., 2008). During 2009
the NHS Plymouth Executive Team agreed to the adoption of a
prioritisation process, based on PBMA, to set priorities for 2010/11.
During the implementation of the process the South West Strategic
Health Authority (SHA) set NHS Plymouth the challenge of making
20 million savings over a three-year period, starting in 2010/11,
and this became a key focus of the prioritisation process. This paper
describes the implementation of the prioritisation process and its
subsequent evaluation. It provides a reection therefore from the
coalface about the usefulness of PBMA for decision-making, as well
as sharing lessons learned about the challenges and benets of
implementing such an approach and offering suggestions for how
the standard PBMA process can be rened to meet the specic
needs of local healthcare commissioners.
The research questions addressed by the evaluation were:

Design methods
Mitton and Donaldsons seven-step approach to PBMA informed
the design of the process (see Appendix 1) (Mitton & Donaldson,
2004). In a novel development of this approach, we split the process into two stages to generate two levels of priorities: high-level
Strategic Improvement Priorities (the SIPs), and more detailed
priorities for changes to specic services (the initiatives). This
aimed to improve the alignment between the PCTs strategic and
operational planning. The process is summarised in Fig. 1.
PCT analysts compiled a programme budget, locally dubbed the
Evidence Bank, using activity, cost, needs, performance, quality,
and user experience data. They analysed the data to produce a
number of recommendations, which were debated at a meeting of
the PCTs Executive Team with representatives of Plymouth Hospitals NHS Trust and Plymouth City Councils Adult Social Care
Department. This resulted in the adoption of nine SIPs for NHS
Plymouth (see Appendix 2).

1. How effective was the new prioritisation process for NHS

Plymouth?
2. To what extent does PBMA provide an appropriate method for
local healthcare resource allocation?
3. Can PBMA be used to identify savings, as well as options for
service improvement?

Methods
What is PBMA?
The rst stage of the PBMA process involves drawing up a
programme budget. This comprises a map of existing activity and
expenditure across all programme areas (e.g. cancer, obstetrics)
and provides an understanding of the existing deployment of
resources. Using this knowledge, a multi-disciplinary panel made
up of managers, clinicians, and other stakeholders devise a list of
options for change to the existing pattern of resource allocation.
There are three types of option: service redesign to provide the
same output for fewer resources (improving technical efciency);
service improvements requiring additional resources; and disinvestments, i.e. services that could be scaled back or discontinued.
These options are then scored and ranked against a predetermined set of criteria, which reect the aims and values of the
organisation. The ranked list is then used to trade-off options
that require additional investment against those that will yield a
release of resources, substituting items with least benet to fund
items with the most benet (thus improving allocative efciency).
Through this marginal analysis, the resources available to the
healthcare organisation are shifted towards programmes that
contribute the most to the organisations strategic objectives
(Mitton & Donaldson, 2004).
Although this paper focuses primarily on reporting the evaluation of PBMA, a great deal of resource was invested in adapting the
process to t with the unique features of NHS Plymouth as a local
organisation. The rst part of this section describes this adaptation
process; the research methods developed for the evaluation of
PBMA then follow.

163

Fig. 1. Prioritisation process owchart.

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E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

A small group of staff developed and piloted a set of prioritisation criteria, which were based on the values of NHS Plymouth as
published in its Strategic Framework (see Appendix 3). The Professional Executive Committee (PEC) approved the criteria, thereby
involving clinicians and directors (Mitton & Donaldson, 2004).
Nine multidisciplinary Health Programme Groups, comprising
clinicians and managers from a range of disciplines, developed
proposals and business cases for initiatives to deliver the SIPs, using
the Evidence Bank to identify potential quality or productivity
improvements. Finance staff created a nancial template to enable
the net present value of each initiatives short and long term
nancial impacts to be calculated (Law, 2004). A multidisciplinary
panel scored each initiative against the prioritisation criteria.
Finally, the PEC debated the suggested initiatives on the basis of
their scores against the prioritisation criteria and nancial information, involving clinicians and directors from NHS Plymouth and
Plymouth Hospitals NHS Trust in selecting the nal set of initiatives
for implementation.
Evaluation methods
We formulated research questions on the basis of a conceptual
framework, which was informed by a review of the literature on
implementing PBMA and issues raised in discussions with stakeholders (see Appendix 4) (Miles & Huberman, 1994).
Qualitative methods are particularly suited to process evaluation. While quantitative methods can tell you what has happened,
qualitative methods are better for illuminating why things have
happened, what effect this has had, and how things could be
improved (Clarke & Dawson, 1999). We undertook semi-structured
expert interviews with staff involved in the prioritisation process,
as they were best placed to describe its effectiveness and to suggest
improvements. One-to-one interviewing allows in-depth exploration of individuals views and experiences. The semi-structured
approach ensures coverage of all aspects of the research question
dened a priori, while enabling the participant to bring his/her own
perspective to bear, often revealing important unexpected ndings
(Flick, 2002; Marshall & Rossman, 1995; Posavac & Carey, 1992).
The main researcher for this evaluation was a Health Economist
employed as a permanent member of NHS Plymouth staff, who had
also led the design and implementation of the prioritisation process. She was responsible for developing the sampling strategy and
interview guides, conducting all interviews, recording these using a
digital Dictaphone, overseeing the verbatim transcription of recordings, and leading the data analysis. We adopted a purposive
sampling strategy (Silverman, 2010) and selected 13 from a possible
26 staff members in order to represent different roles within the
process, roles within the organisation (e.g. clinician, director,
manager), and functions (e.g. nance, primary care, public health).
We developed different interview guides for participants with
different roles, varied the wording and order of the questions to
allow the interviews to unfold naturally, and spontaneously added
additional questions to probe new themes that emerged during the
interviews (see Appendix 5) (Flick, 2002).
We identied the key themes emerging from the interviews
using a thematic coding process (Flick, 2002). Although the process
was primarily inductive, there was also a deductive element, as the
research questions inuenced some themes. We noted each new
theme, and gradually organised the themes into categories using
the qualitative analysis software NVIVO. We explored how the
themes related to one another by applying the resulting coding
frame back onto the data (Coffey & Atkinson, 1996). Analytic rigour
was enhanced by checking the interpretation of the data with the
second author and with research participants subsequent to
interview.

The fact that the interviews and analysis were conducted by the
main architect of the prioritisation process could constitute a risk of
biasing the results: the interviewer may have a vested interest in a
favourable result, and participants may feel uncomfortable criticising the process. Previous research into PBMA implementation,
however, suggests that this is mitigated by the fact that the interviewer had worked closely with the research participants, as a
colleague, to develop and implement the process (Patten, Mitton, &
Donaldson, 2006). From the researchers point of view, the aim was
to develop the process over a number of years, rather than getting it
right rst time, enabling criticism from colleagues to be perceived
as a constructive factor in achieving a long-term vision. This was
assisted by keeping a reexive research diary, which included
personal reactions to critical comments. Participants were assured
that constructive criticism was welcome, and central to improving
the process. Interview error is common in evaluation research, as
staff may avoid expressing views of which managers may disapprove (Marshall & Rossman, 1995). Reassurance was provided by
ensuring that all participants were aware of condentiality.
Research participants were advised that their views on the
process were being sought in order to evaluate the process and its
implementation, and to inform future improvements. All participants signed consent forms prior to interview (Gray, 2004). No
person-identiable information was used. Digital recordings and
transcripts were password-protected, recordings were deleted
once the transcriptions had been checked, and all transcripts were
anonymised.
Results
All 13 people approached were happy to participate in the interviews, although one was unable to attend. The interviews ranged
from 35 to 80 min in length, and their content varied considerably
depending upon the interests and concerns of each interviewee.
Those interviewed included: SIP leads, i.e. the service improvement
and commissioning managers who led the teams responsible for
developing the initiatives; clinicians, nance, performance and
contracts staff, who contributed to the development of the initiatives; those who ran the implementation of the prioritisation
process; and members of the PEC, who were responsible for
agreeing the nal list of prioritised initiatives. Interviewees
comprised staff responsible for the acute care contract, primary
care, mental health and learning disability services, and public
health. The results for each dimension of the conceptual framework
that related to the outcomes of the prioritisation process are discussed below.
How satised were participants with the process?
People were unanimously happy with the process as a concept.
A key reason for this was that the process was universally considered an improvement. The process was applauded for being
robust, structured, evidence based and systematic, in
contrast to the PCTs previous approach to resource allocation,
which was criticised by several participants e particularly those
lower down the organisational hierarchy e for involving decibel
rationing. These participants welcomed this more inclusive,
evidence-based process as a means of limiting the power of inuential individuals to determine priorities. At the same time, the
combination of technical and political approaches to prioritisation
inherent in the process was valued by some, including both clinicians, who appreciated the opportunity to offer expert opinion.
For some participants the ability to compare initiatives and
trade off investments against disinvestments was an important
feature of the process, while others struggled to grasp the concept.

E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

This difculty was apparent both during the interviews and during
the implementation, where the concept of trading off proved to be
the most challenging aspect of the process to explain to
participants.
Although participants were satised with the concept of PBMA,
several of those who were involved in developing initiatives reported that tight timescales and uncertainty around some aspects
of the process implementation had caused anxiety and pressure.
Fortunately, however, most felt that the PCT had made a good start.
Even as we were struggling to try and deliver things quickly, all
the way through the process I just thought that I actually like
what were trying to achieve.
Participants were condent that the process would be used again
in the future. They did suggest a number of improvements, none of
which were fundamental: better timing, more capacity for developing business cases, improved quality of business cases, more
stakeholder involvement, and better links to capacity planning.

challenges. The estimated savings accruing from the initiatives,

however, were insufcient to meet the nancial target for 2010/11.
Only one initiative represented a true disinvestment, although the
majority offered technical efciencies. To investigate this, participants were asked to identify barriers to ideas for disinvestment.
Participants from the Finance Directorate pointed out that the
concept of disinvesting represents a major cultural shift, following
years of increasing investment in the NHS. Moreover, they felt that
considerable scope exists for technical efciencies, and the ethical
approach is to tackle these before seeking to disinvest.
Thats natural and its right.
Those involved in running the process implementation
wondered whether the capacity to generate and deliver initiatives
was limited, because the SIP leads were relatively junior to be
proposing large scale changes with major nancial implications.
Support from directors was therefore considered a key factor in
granting the SIP leads a mandate to propose disinvestments, and
comments from the SIP leads corroborated this.
Im not sure weve been given permission to be that radical.

How fully did NHS Plymouth comply with the process?

When asked about the extent to which they had adhered to the
process, the majority of participants felt that they had mostly, but
not fully, complied.
I think we stuck with the process. About 90%.
Their responses revealed three ways in which they strayed from
the process. Firstly, several people felt that certain initiatives were
not derived from the SIPs or the Evidence Bank. This was corroborated by the SIP leads, who described how the Evidence Bank had
reinforced existing ideas, rather than inspired new ones.
Secondly, a few people expressed concern that decibel rationing
occurred during the PEC prioritisation meetings, at which the SIPs
and the prioritised list of initiatives were agreed, and that this took
precedence over the Evidence Bank.
Those with the biggest inuence are getting their way.
Finally, several participants felt that the initiatives could have
been subjected to a more challenging debate at the PEC meetings.
When questioned about this, the decision-makers who were
interviewed expressed a reluctance to criticise or reject initiatives
for fear of demotivating staff.

165

Attitudes towards nancial considerations differed between

roles. SIP leads and clinicians felt that nancial benets were too
highly weighted, resulting in projects with potentially high health
gain receiving too low a priority. Although they recognised the
importance of balancing the budget, they found this difcult to
reconcile with their roles, which they perceived as being to improve
health. Conversely, nance, performance, and contracts staff felt
that nancial balance should be weighted more highly than healthrelated benets.
The technical efciencies identied by the process resulted in a
substantial reduction in hospital activity, which was one of the
main aims of the prioritisation process. Table 1 compares hospital
activity levels for NHS Plymouth with overall gures for England,
using 2009/10 as a baseline.
NHS Plymouth showed a reduction in total non-elective admissions and rst outpatient attendances, against a national
backdrop of increases in both. The increase in elective daycases
represents a shift from inpatient admissions, involving an overnight stay. Whereas nationally the decrease in elective inpatient
admissions was more than offset by an increase in daycase activity,
NHS Plymouth increased the number of procedures undertaken as
daycases while achieving an overall reduction in elective activity.

What were the main outcomes of the process?

Despite the concerns outlined above, all participants expressed a
general feeling that the process had produced the right priorities.
Several stated that, rather than changing the priorities of the organisation, the process had made these priorities more explicit, using
words like visibility, awareness, and corporate vision. Participants considered this to be one of the most important outcomes of
the process. They described how the SIPs had become known and
understood throughout the organisation, providing a clearer strategic direction, and greater awareness among staff of the PCTs priorities. A large majority of participants took this concept further,
explaining that the unprecedented clarity around NHS Plymouths
priorities provides staff with a focus and structure that was previously lacking, helping them to prioritise their workload and the
deployment of resources and effort. In this way, the process was felt
to have aligned the PCTs day-to-day work to clear strategic priorities.
The potential for the process to provide an appropriate means of
achieving the required level of nancial savings was recognised by
several participants, by providing ethically sound criteria on which
to base these decisions, and a robust structure to deal with nancial

Table 1
Change in hospital activity levels (general and acute), 2009/10e2011/12.
Non-elective First outpatient
Elective
Elective
Elective
attendancesc
total
total
ordinary
daycase
a,b
admissions
admissions admissions admissions
England
2009/10
2010/11
2011/12
Total
change

1,628,113
1,593,215
1,567,446
3.73%

NHS Plymouth
2009/10 9041
2010/11 7624
2011/12 7494
Total
17.11%
change
a

5,267,244
5,547,697
5,830,730
10.70%

6,895,357
7,140,818
7,398,177
7.29%

5,235,766
5,458,026
5,404,048
3.21%

15,276,762
15,836,204
15,914,410
4.17%

25,362
24,010
26,216
3.37%

34,403
31,634
33,710
2.01%

29,231
27,790
25,675
12.17%

74,969
70,937
72,751
2.96%

Admissions rst nished consultant episodes.

Ordinary admissions inpatient admissions, including at least one overnight
stay.
c
First outpatient attendances rst consultant outpatient attendances.
Source: Department of Health Hospital Activity Statistics 2009/10e2011/12.
b

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E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

Table 2 provides examples of specic shifts in activity related to

particular initiatives.
A number of indirect benets arising from the process were
identied by participants. The most important of these for participants was their perception that the prioritisation process was a key
factor in driving positive changes in the organisational culture, and
this was actively welcomed.
Its starting to change probably the hearts and minds right from
the top, across the organisation.
A wide range of participants felt that the process had engendered a greater understanding of what other parts of the organisation were doing, and encouraged more joined-up working.
I think it has brought everybody together, I think thats the
biggest thing its done.
A further indirect benet was raising awareness of the need for
effective priority setting not to rely on a few individuals to lead, but
rather to rely on a more system-led and shared approach to leadership. The process was credited for giving a higher prole, and
greater priority, to services outside secondary and primary care,
specically mental health, learning disability, and public health.
This was particularly valued by participants representing these
service areas, who had previously felt marginalised in debates
around resource allocation.
Some participants commented that the process provided a
structured and standardised approach to planning that had previously been lacking. As earlier comments about decibel rationing
have suggested, participants felt that resource allocation decisions
had traditionally been taken by individual directors, with little
consultation. The prioritisation process was perceived to restrict the
inuence of powerful individuals, by providing a more evidencebased, systematic, and democratic approach to decision making.
A salient cultural issue, given the English NHSs current move to
clinical commissioning, was raised by both the GPs interviewed.
Table 2
NHS Plymouth commissioned activity and expenditure related to specic initiatives,
2009/10e2012/13.

Number of diabetic rst

and follow-up
outpatient attendances
Cost of diabetic rst and
follow-up outpatient
attendances (000s)
Orthopaedic non-trauma
activity at Plymouth
Hospitals NHS Trust
Orthopaedic non-trauma
expenditure at Plymouth
Hospitals NHS Trust (000s)
Estimated number of
admissions avoided due to
the introduction of long-term
conditions managers
Number of people with three or
more admissions in the
preceding 12 months, linked
to the introduction of risk
stratication/long-term
conditions managers
Number of emergency admissions
for COPD, which had previously
been increasing by 9.8% pa,
linked to the introduction of a
Telehealth initiative

2009/10

2010/11

2011/12

2012/13

6715

6562

5607

4947

876

936

793

719

2721

2732

2413

2276

7366

6479

7039

6310

362

712

751

1808

2200

2156

2004

They stated that, having been trained to make complex clinical

decisions within a timescale of a few minutes, GPs nd technical
processes long-winded, slow, restrictive, and frustrating. They feel
they already know what the priorities are and how to tackle them,
and just want to get on with it. However, they both accepted that
this is not a robust basis for resource allocation, and they welcomed
the process as a mechanism by which clinicians and managers can
work together constructively to set healthcare priorities.
Initially it was a pain in the backside, from my point of view, but
as you go along you suddenly realise .
Some participants felt that the process enhances accountability,
enabling the PCT to justify its priorities and explain the rationale
behind them to patients, the public, staff, and other stakeholders. A
couple of participants considered that the process had given staff a
sense of ownership of the organisations priorities and responsibility for shaping them. Finally, some participants considered
the experience of implementing the process to have engendered
organisational learning about the PCTs organisational processes,
structures, functions, and cultural factors.
How well integrated is the process with the culture, structure and
wider processes of the PCT?
Compatibility with existing structures and processes was not
perceived as a major issue, as participants felt the process provided
a structure that had previously been lacking. A majority, however,
pointed out that they fell at the nal hurdle by failing to link into
the annual capacity plans that they negotiate with their providers
to agree activity levels for the following year. This was due to
timing: the capacity plans had to be completed before the initiatives were fully drawn up. Once the timing issues were rectied,
participants believed that the process would provide a valuable
input into capacity planning.
The interviews, however, revealed that integrating the process
into the structures of the PCT alone is likely to prove insufcient in
dealing with the current challenges facing the NHS. All bar one
participant recommended adopting a health community-wide
perspective to prioritisation, rather than remaining focused on
NHS Plymouth as a commissioner. Plymouth NHS Hospitals Trust
was the most frequently mentioned stakeholder, the others being
the NHS Plymouth provider arm and Plymouth City Council. Participants believed that fully involving key stakeholders throughout
the process, in agreeing the SIPs, developing business cases, and
prioritising and implementing initiatives, will enhance ownership
and increase the likelihood that the initiatives will realise their
aims e it is only by providers changing their behaviour that service
delivery will change. Furthermore, nance and contracts staff
pointed out that focusing on saving money as a commissioner runs
the risk of destabilising providers nancial positions, whereas joint
planning enables delivery of a sustainable programme of disinvestment across the health community. In this way the current
nancial situation is providing a strong incentive to work together,
and the prioritisation process needs to reect this.
Discussion

NA

NA

690

631

Sources: Dr Foster; NHS Northern, Eastern and Western Devon Clinical Commissioning Group.

The prioritisation process succeeded in producing strategic

priorities (the SIPs) and operational service improvement priorities
(the initiatives). Most participants felt that these were the right
priorities. The initiatives have succeeded in achieving a substantial
planned reduction in hospital activity levels.
However, the timescales and resources available for developing
initiatives were limited, and unforeseen issues caused aspects of the
process to require modication during the implementation,

E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

resulting in some confusion. Starting the process late in the year

limited the time and support available for SIP leads to develop initiatives, which may provide an explanation for their tendency to
recycle existing ideas and propose insufcient disinvestment opportunities. An important source of support that was lacking was
from the Finance Team, in estimating the nancial implications of
the proposed initiatives, leading to a lack of robust nancial projections to inform decision-making. This arose in part from the
initiative development stage of the prioritisation process coinciding
with the development of the Medium Term Financial Plan, which
occupies the Finance Team full-time during this period. In addition,
further skills development may be necessary to enable staff to produce nancial estimates. Crucially, the timing of the process meant
that details of the initiatives were not available to inform capacity
planning. It is paramount that this is addressed: failure to integrate
PBMA with wider planning processes presents a barrier to achieving
changes in patterns of service delivery (Kemp et al., 2008).
The two-stage process design whereby strategic priorities were
agreed prior to developing specic initiatives proved highly successful, resulting in unprecedented clarity of the PCTs vision and
objectives, and linking the day-to-day work of staff to clear strategic
aims. Participants expressed strong approval for the process, nding
the structured and evidence-based approach a signicant improvement to previous practices. No systematic approach to resource
allocation had previously been implemented by NHS Plymouth;
participants suggested that nancial decisions had been taken by
powerful individuals, and that weak planning processes had resulted
in a lack of clear strategic priorities and work-plans. Eddama and
Coasts (2009) research suggests this is not unusual for a PCT. A
major outcome of the prioritisation process has been to challenge
this, and to provide a driver for the positive cultural changes that
participants perceive to be taking place, reecting ndings from the
literature about PBMA engendering organisational change (Halma,
Mitton, Donaldson, & West, 2004). A recurring theme from the interviews was participants disapproval of decibel rationing. This was
a major criticism levelled against NHS Plymouths previous approach
to prioritisation, particularly by those further down the hierarchy,
reecting Mitton, Patten, et al.s ndings that a lack of an explicit
prioritisation process causes managers and clinicians to question the
credibility of resource allocation decisions (2003). A key reason for
participants approval of PBMA was that it limited decibel rationing,
and some were keen to highlight concerns that this was still occurring in the PEC prioritisation meetings. The SIP leads, however, were
unconcerned that they had developed some initiatives prior to
seeing the Evidence Bank, citing expert opinion. An interesting tension emerges: at what point does expert opinion (perceived as a
positive feature of PBMA) become decibel rationing (perceived as
negative)? Analysis of the interviews suggests that those higher up
the hierarchy are seen to engage in decibel rationing, whereas less
powerful individuals offer expert opinion, potentially leading to an
over-estimation of the formers involvement in decibel rationing.
This in turn may explain the apparent discrepancy between participants perceptions of decibel rationing and their approval of the
chosen SIPs and initiatives. The PBMA process, however, enables less
powerful individuals to participate in decision-making (Gibson,
Martin, & Singer, 2005). In doing so, how does one ensure that
these new stakeholders do not take up the mantle of decibel rationing themselves? There is a balance to be struck: efforts to limit
decibel rationing should not act to stie expert opinion, as the
combination of technical and political approaches to prioritisation is
a strength of PBMA (Wilson et al., 2009).
Published accounts of PBMA applications suggest that limited
suggestions for releasing resources tend to be put forward (Mitton,
Peacock, Donaldson, & Bate, 2003). In the Plymouth case, although
only one initiative represented a true disinvestment, the majority

167

offered technical efciencies. Many of the initiatives sought to couple

efciency savings with service improvements, reecting the strongly
expressed perception by SIP leads of their role being to improve
services. Finance staff, too, believed that disinvestments should not
be considered until opportunities for technical efciency are
exhausted. Barriers to disinvestment included limited capacity for the
development and implementation of initiatives, and the position of
SIP leads in the organisational hierarchy, the latter pointing to a key
role for directors in supporting staff to participate in the process. A
reluctance to disinvest is unsurprising, as periods of increasing government investment in healthcare, such as that enjoyed by the NHS in
the preceding decade, do not promote a culture of resource reallocation (Mitton, Donaldson, Waldner, & Eagle, 2003). The process did,
however, produce technical efciency improvements, which can
provide a catalyst for healthcare organisations to accept disinvestment (Mitton, Patten, et al., 2003). A further driver for future disinvestment is the current budgetary pressures facing the NHS. All
participants recognised the inevitability of meeting nancial challenges e although nance and performance staff were more
comfortable with this than their service improvement, commissioning, and clinical colleagues e and the prioritisation process was
felt to be an appropriate vehicle for achieving this.
The intention was that the Professional Executive Committee
would rst consider ideas for improving technical efciency, i.e.
achieving comparable outcomes at less cost, followed by ideas for
disinvestment, selecting those with the lowest benet scores to
minimise detrimental impacts. Once the 20 million savings stipulated by the Strategic Health Authority had been identied, trade-offs
between further disinvestments and projects requiring additional
investment would be made. The nancial estimates, however, suggested that the proposed initiatives totalled less than the required
level of savings, therefore all the initiatives that offered savings were
approved, leaving no available resource to fund initiatives requiring a
net investment. Nevertheless, two initiatives that required investment were approved by the PEC, pending sufcient funding being
released by other projects, despite the fact that this funding was
already earmarked for the necessary budgetary reduction. This reects a level of confusion about the marginal analysis part of the
process. It was certainly the most challenging aspect of PBMA to
explain to participants, and some difculty in grasping the concept
was evident in the interviews. This suggests a need (reected in the
literature) for more education around the key economic principles of
PBMA, which are unfamiliar to most managers and clinicians
(Mitton, Donaldson, et al., 2003). Of more concern, perhaps, was a
perceived lack of robust debate and challenge around the business
cases presented to PEC. Decision-makers expressed a reluctance to
turn down initiatives for fear of demotivating staff. This cultural
feature must be addressed if PBMA is to work effectively.
A major theme of the interviews was the perceived need to move
from a commissioner to a healthcare community perspective, incorporating healthcare providers and the local authority. Participants felt
that a failure to engage the wider healthcare community in priority
setting could jeopardise the realisation of these priorities where this
is reliant on external stakeholders changing their patterns of service
delivery (Mitton, Patten, et al., 2003). They suggested that joint
planning could ensure that any planned reductions in commissioned
activity do not destabilise the nancial position of providers. This
provides a potential solution to concerns raised by Mitton,
Donaldson, et al., (2003) about the applicability of PBMA to healthcare environments characterised by a structural separation between
commissioners and providers. Plymouths organisational boundaries
provided a useful facilitator for tackling this challenge: local data
shows that over 90% of NHS Plymouths acute activity was commissioned from PHNT, and the PCTs catchment area was coterminous
with that of Plymouth City Council.

168

E. Goodwin, E.J. Frew / Social Science & Medicine 98 (2013) 162e168

A key strength of this application of PBMA was that the design of

the process was based on the ndings of a comprehensive literature
review undertaken by a health economist, and was specically
tailored to the organisational context of NHS Plymouth. The use of
qualitative methods for evaluation provided a further advantage:
qualitative approaches are particularly effective in illuminating
why things have happened, what effect this has had, and how
things could be improved (Clarke & Dawson, 1999). Both the
implementation and the evaluation, however, were undertaken in a
single, small PCT, in a health and social care environment dominated by one major secondary care provider and one unitary local
authority, possibly limiting the generalisability of the results.
Further research into the effectiveness of alternative technical
approaches to priority-setting, or in healthcare environments
characterised by a greater plurality of providers, would provide a
valuable contribution to the literature, and produce results that are
generalisable to a wider range of commissioner and provider settings. At the time of writing, discussions are underway to apply the
PBMA approach across the Plymouth healthcare community within
specic care pathways, and this could also provide fertile ground
for future research.
In conclusion, this research indicates that PBMA offers a practical and effective method for resource allocation decision making
at a local level. One interesting nding is that, despite initial misgivings, clinicians in Plymouth acknowledged the advantages of a
more technical approach to decision-making once they had
participated in the process. This echoes previous research that
suggests involvement in PBMA enhances the ability of clinicians to
engage with system-wide resource allocation (Harrison & Mitton,
2004). The PBMA process provides a useful framework for clinical
leadership, through setting prioritisation criteria, working together
with management support staff to devise initiatives, agreeing
strategic priorities and specic initiatives to improve efciency and
patient outcomes, and spearheading the implementation of these
initiatives. While this is of particular relevance in the English NHS,
given the imminent transfer of commissioning responsibilities
from PCTs to Clinical Commissioning Groups, PBMA may also provide a useful vehicle for any healthcare system seeking greater
clinical involvement in population-wide decision-making.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2013.09.020.

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