Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis

Keogh, Fiona; Pierse, Tom; O'Shea, Eamon; Fitzgerald, Christine; Challis, David

Abstract

Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices.
Methods: A balance of care approach was used to assess resource allocation across six dementia case types, from low to high needs. Workshops were held with 24 HSCPs from multiple disciplines. Participants allocated services in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach.
Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants were proficient in making decisions, using ‘decision rules’ or heuristics to help them make decisions under fixed budget rules and sticking to conventional provision when constraints were in place.
Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.

Citation

Keogh, F., Pierse, T., O'Shea, E., Fitzgerald, C., & Challis, D. (2020). Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis. HRB Open Research, 3, Article 69. https://doi.org/10.12688/hrbopenres.13147.2

• Journal Article Type: Article
• Acceptance Date: Dec 14, 2020
• Online Publication Date: Dec 14, 2020
• Publication Date: Dec 14, 2020
• Deposit Date: Jan 18, 2021
• Publicly Available Date: Jan 18, 2021
• Journal: HRB Open Research
• Print ISSN: 2515-4826
• Publisher: F1000Research
• Peer Reviewed: Peer Reviewed
• Volume: 3
• Article Number: 69
• DOI: https://doi.org/10.12688/hrbopenres.13147.2
• Keywords: Dementia, resource allocation, heuristic, context, health and social care
• Public URL: https://nottingham-repository.worktribe.com/output/5173492
• Publisher URL: https://hrbopenresearch.org/articles/3-69/v2
• Additional Information: Referee status: Approved, Approved with reservations; Referee Report: 10.21956/hrbopenres.14338.r28545, Michael Donnelly, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK, 17 Dec 2020, version 2, 1 approved, 1 approved with reservations; Referee Report: 10.21956/hrbopenres.14263.r28182, Deirdre O'Donnell, School of Nursing, Midwifery and Health Systems, University College Dublin (UCD), Dublin, Ireland, 19 Nov 2020, version 1, 1 approved, 1 approved with reservations; Referee Comment: Fiona Keogh; ; Posted: 07 Dec 2020; Thank you Deirdre for reviewing our paper and for the detailed observations and comments which have been very helpful. We have made the following changes to the paper in response: A paragraph on the BoC approach has been added to the Discussion Further detail on the HSCP participants and their working environment has been provided in the Methods. The absence of physicians from the workshops is discussed as a limitation. Further clarity is provided on the selection of participants for follow-up interviews and the source of data reported in the paper. Detail providing clarity on the participants in the workshops has been provided in the Method. Given the group nature of the discussions it was not possible to attribute comments to individuals or disciplines. Comment has been added to the Discussion on the absence of marked differences between disciplines in the decisions made. Comment has been added to the Method and Discussion on service availability in Ireland and the reaction of participants to gaps in services. Detail has been added to the Method to explain the way in which participants could allocate services. The distribution of resource across case types will be covered in a future paper, that will show how participants react to need across case types, especially when budget constraints apply. Further discussion is beyond the scope of the current paper. Many thanks for your considered comments which have enhanced the paper. We also appreciate your positive comments.; Grant Information: Health Research Board and National Dementia Office [APA-2016-1876]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.; Copyright: This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.