Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting

Abstract

BackgroundThis is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective.DiscussionFour themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment.There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term ‘disinvestment’ should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches.The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed.A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon.The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers.There is little evidence of successful implementation of ‘disinvestment’ projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs.ConclusionsThese findings suggest that the construct of ‘disinvestment’ may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2507-6) contains supplementary material, which is available to authorized users.

Bibliometric Review of the Knowledge Base on Healthcare Management for Sustainability, 1994–2018

“…More specifically, author co-citation analysis revealed three schools of thought in the SHM literature: (1) sustainable change in health care services, (2) innovations in managing health care operations, and (3) prioritizing and allocating resources for sustainability. The science map of the SHM literature highlighted both the micro-level focus on healthcare management in organizations [11,13,49,63,66], as well as macro-level issues in healthcare systems [70][71][72][73][74][75][76][77].…”

“…Key authors include five Australian scholars: Harris with 77 co-citations [70][71][72][73][74][75][76][77], Allen with 53 co-citations [70][71][72][75][76][77], King with 44 co-citations [70][71][72][75][76][77], Elshaung with 42 co-citations [74,[78][79][80], and Mitton with 42 co-citations [78,81]. Key literature within this School centers on a series of 11 research papers published under the acronym, 'SHARE' or 'Sustainability in health care by allocating resources effectively' [70,[72][73][74][75][76][77][82][83][84]. These papers investigated the process of disinvestment in the Australian health services network using an evidence-based approach.…”

How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners

“…Given concerns raised in the literature around the use of terms in the area of resource allocation,16 as part of the context for the study, some key terms will be defined here. The study adopts an economics-based perspective as its theoretical underpinning and was concerned with how priorities are set for resource allocation.…”

Sustainability of healthcare systems in Asia: exploring the roles of horizon scanning and reassessment in the health technology assessment landscape

“…Passive HTR may be achieved simply by education and the dissemination of information without the need for direct intervention from policy makers. Clinicians often stop using a technology when a better alternative becomes available, as is often the case with surgical procedures (6). The overlapping S curve model in Figure 2 more accurately describes the reality of health systems, where the introduction of new technologies is a continuous, overlapping process.…”

“…In an ideal health system, existing clinical practices and technologies should be subject to ongoing review and continuous evaluation in order to identify the instances of poorly coordinated care, duplication or gaps in service delivery, practices that encourage overtreatment or overdiagnosis, ineffective practices or systemic waste (6), or new uses for existing technologies (3).…”