Accountability for Reasonableness for Priority Setting

Accountability for Reasonableness for Priority Setting Essay Accountability for Reasonableness, for priority setting and resource allocation. INTRODUCTION Pakistan as a developing country has very limited health care resources when  considering a huge population of over 170 million. We have very few tertiary care  hospitals and they are providing services to the whole country. Majority of people in  our country are poor and they are unable to afford the expenses of private hospitals,  though private hospitals are also very few. Thousands of doctors are unemployed  and still we have shortage of doctors. Majority of BHU (Basic Health Units) are  closed as majority of doctors belong to urban areas and they don’t want to work in  remote village areas. In all these situations, it is very difficult to maintain health  care throughout country. In this essay, I will take into account four conditions of  accountability for reasonableness for priority setting and resource allocation. I will  take into account these four conditions by Norman Daniels and I will consider a  tertiary care hospital scenario where I did my house job in medicine ward last year. There were majority of patients suffering from chronic liver diseases (CLD). I will  further continue this essay in discussion. DISCUSSION Before discussing the four conditions of accountability for reasonableness, I will  briefly discuss the case scenario. In my medicine ward as I earlier said majority of  patients were of chronic liver diseases (CLD) and it includes Hepatitis B, Hepatitis C  and cirrhosis of liver. Cirrhosis is the end result of hepatocellular injury that leads  to both fibrosis and nodular regeneration throughout the liver. The clinical features  result from hepatic cell dysfunction, portosystemic shunting, and portal  hypertension. Cirrhosis may cause no symptoms for long periods. One of the major  complications is uppergastrointestinal tract bleeding which may occur from varices,  portal hypertensive gastropathy, or gastroduodenal ulcer. Hemorrhage may be  massive, resulting in fatal exsanguinations or enencephalopathy. Esophageal varices  are found in 50 % of patients with cirrhosis. There are several treatment and  management options available for esophageal varices includin g acute resuscitation  as initial management, pharmacologic therapy, balloon tube tamponade, portal  decompressive procedures and emergent endoscopy. Endoscopic techniques are also  used for prevention of Rebleeding. 1. Now, I will discuss my case scenario. In our  hospital there is one associate professor who is trained in doing endoscopy and  Wednesday is fixed for performing endoscopies. Emergent endoscopy is performed  after the patient’s hemodynamic status has been appropriately stabilized (usually  within 2-12 hours). Majority of poor patients come to hospital in end stage liver  diseases. I have taken this case series as it is a perfect example of scarce resources. Many patients faced problems as their endoscopies were not performed on time as  there was only one day fixed in a week. Now I will apply the four conditions of  accountability for reasonableness for priority setting and resource allocation. These  four conditions are publicity condition, relevance condition, revisions and appeals  condition and regulative condition. Accountability for reasonableness makes it  possible to educate all stakeholders about the substance of deliberation about fair  decisions under resource constraints. It facilitates social learning about limits. It  connects decision making in healthcare institutions to broader, more fundamental  democratic deliberative processes. 2. In my case scenario I will apply the four  conditions as follows. The first one is publicity condition. It states that decisions  regarding limits to care and their rationales must be publicly accessible to clinicians,  patients, and citizens in a publicly administered system. When the patients suffer  the complication of esophageal varices, they are informed about the limited capacity  of the ward to arrange endoscopy as it is done on only Wednesdays and surgical  ward have their own burden of patients to be done endoscopies, due to this reason  we were unable to send patients to surgical wards and the patients and their  relatives mostly agrees on this setup and if their was any emergency only then we  take help from surgical ward or send the patients to any other hospital, so the first  condition is fulfilled. In above scenario second condition is also fulfilled which isrelevance condition. It states that the reasons for limit-setting decisions will be  reasonable if it appeals to evidence, reason, and principles that are accepted as  relevant by fair-minded people who are disposed to finding mutually justifiable  terms of cooperation. In my case scenario the decision making is according to the  framework. The rationales w ere reasonable as it is evident that we had limited  facility of endoscopy and it was fairly accepted by patients and their relatives and  also by doctors and other hospital staff. In our setup priority was given to those  patients who needed emergency endoscopy rather than those who requires  endoscopy for diagnostic procedures. The third condition is revisions and appeals  condition. This condition is a very common problem in government hospitals and in  our scenario we request consultants from surgical ward to do emergency endoscopy  if we think patient is serious and he or she may die if the endoscopy is not  performed on time or in other case the other hospital is very far so that it will be late  if we send the patient to other setup and here comes the function of oncall  consultants also, the oncall consultants plays huge role in these emergency  situations. This third condition is a mechanism for challenge and dispute resolution regarding limit setting decisions, including the opportunity for revising decisions in  light of further evidence or arguments. 3. Thus we fulfill the third condition also by  revising our decisions as I explained above. The fourth and last condition is  regulative condition or enforcement. There is either voluntary or public regulation  of the process to ensure that conditions 1-3 are met. This condition is also fulfilled in  our setup as we communicate with the patient and their relatives about our limited  resources. We are able to convince patients in our case scenario. The hospital  leadership is constantly making efforts to meet the conditions of ‘accountability for  reasonableness’. 4. CONCLUSION In this essay I have discussed all four conditions of accountability for  reasonableness, for priority setting and resource allocation. ‘Accountability for  reasonableness’ is a framework that can be used to guide legitimate and fair priority  setting in health care organizations, such as hospitals. In our beloved country  Pakistan we have few government civil hospitals bearing the burden of millions of  population. We try our best to server the humanity. Iam not claiming this system a  perfect one, it needs a lot of improvement and the example is my case scenario in  which we have very limited resources. Government should establish civil hospitals in  small cities also and should increase their budget; they should recruit more doctors  and nurses as we have shortage. They should train doctors with latest equipments  and provide hospitals appropriate medicines. In addition to this all the hospitals  should be provided with computers and also be made online so that a data system  can be established and it can help the patients and also hospitals for future  reference. I will conclude by saying that in such scarce resources, government sector  hospitals are doing excellent job. REFERENCES Current Medical Diagnosis and Treatment 2004. 43rd edition. Norman Daniels. (2000). Accountability for reasonableness. BMJ; 321; 1300-  1301. D K Martin, P A Singer and M Bernstein. (2003). Access to intensive care  unit beds for neurosurgery patients: a qualitative case study. J. Neurol.  Neurosurg. Psychiatry; 74; 1299-1303. Jennifer AH Bell, Sylvia Hyland, Tania DePellegrin, Ross EG Upshur, Mark  Bernstein and Douglas K Martin. (2004). SARS and hospital priority setting:  a qualitative case study and evaluation. BMC Health Services Research, 4:36