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Table 3 Issues to consider in development of an organisational program for disinvestment

From: Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting

Topic Issues
Organisational and management ▪ How can a systematic evidence-based approach to disinvestment be implemented in a healthcare organisation? ▪ How can disinvestment decisions be integrated into established Strategic and Business Plans ▪ Which is the better approach – ‘top down’, ‘bottom up’ or both? ▪ How to engage and get ‘buy-in’ from clinicians, consumers and other stakeholders ▪ What are the relevant organisational change mechanisms? ▪ What does leadership for disinvestment involve?
Decision-makers ▪ Who has the authority, and the will, to make and act upon decisions about disinvestment? ▪ Who are the appropriate decision-makers?  – Existing decision-making bodies or specially convened groups  – Composition: policy-makers, managers, clinicians, consumers, technical experts, others  – In-house or external ▪ How does the relevant information get to them? ▪ What other agendas do they bring to the decision-making table? ▪ Who has the time, relevant skills and adequate resources to identify, implement and evaluate the required practice changes?
Decision-making ▪ Are all viewpoints equal? ▪ What criteria should be applied to disinvestment decisions and prioritisation? ▪ What is the nature and source of information required? ▪ How do decision-makers become aware of the need to disinvest certain practices? ▪ How are policies and guidance documents used by local decision-makers to allocate resources?
Assumptions ▪ Are generally held assumptions true? For example  – ‘Clinicians are reluctant to disinvest’  – ‘Disinvestment is not optimal unless an active intervention is in place’
Skills and resources ▪ What expertise and training is required to make, communicate, implement and evaluate decisions? ▪ What resources are required to source expertise, source information, ‘backfill’ health service staff when participating, and support decision-making, implementation and evaluation processes?
Professional and cultural ▪ What impact will professional boundaries and ‘turf’ issues have on disinvestment activities? ▪ What are the rights and responsibilities of stakeholders? ▪ Different stakeholder views of what is meant by ‘little or no health benefit’ ▪ What is the effect of culture on disinvestment? (authoritative versus consultative, transparent versus hidden) ▪ What are the motives and incentives for disinvestment?
Financial and commercial ▪ What funding is required for disinvestment initiatives and where can it be found? ▪ How can the difficulties inherent in the complex funding arrangements within health services be overcome? ▪ How can savings be measured? ▪ How can savings be reinvested?
Values and ethics ▪ How can transparency of process be ensured? ▪ What is a ‘fair and reasonable’ process? ▪ What are the access, equity and legal considerations? ▪ What is the best way to deal with conflict of interest with commercial entities?
Research and evaluation ▪ What effect will the limited evidence base for some practices have on the process? ▪ How can the lack of tested methods for implementation and evaluation be addressed?