Table 2 Key messages and recommendations

Disinvestment in general – key messages

▪ Understanding of systems, processes and influencing factors at the local health service level are important for successful disinvestment.

▪ Single definitions for disinvestment and health technologies, are needed with agreement between researchers, policy makers and health service decision-makers [8, 30]. We propose the following definitions.

 ‑ Disinvestment is removal, reduction or restriction of any aspect of the health system for any reason. Removal indicates complete cessation, reduction is a decrease in current volume or delivery sites, and restriction is narrowing of current indications or eligible populations. This is a broad definition, in essence the conceptual opposite of investment. It is an outcome of, rather than a reason for, a resource allocation decision. It is not burdened with the explanations and caveats of current research definitions. This could apply equally to products, devices and equipment; clinical practices and procedures; health services and programs; information technology and corporate systems.

 ‑ Health technologies are products, devices and equipment used to deliver health care (eg prostheses, implantable devices, vaccines, pharmaceuticals, surgical instruments, telehealth, interactive IT and diagnostic tools). This is a narrow definition which reflects the common use by decision-makers and consumers in the local health care setting. Clinical practices, support systems, and organisational and managerial systems are not considered to be health technologies in this context.

 ‑ Health technologies and clinical practices (TCPs) are therapeutic, diagnostic and preventative interventions (eg use of products, devices and equipment PLUS medical, surgical, nursing, allied health and population health activities). This is a pragmatic definition that reflects the scope of most resource allocation decisions related to delivery of health care in the local setting.

 ‑ Health programs and services are agencies, facilities, institutions and the components within them that deliver acute health care, rehabilitation or population health practices such as health promotion and education.

Disinvestment in general – recommendations

▪ Avoid the term ‘disinvestment’, it is viewed negatively and perceived as ‘cost-cutting’. [8, 23, 26, 30]

▪ Do not to aim ‘to disinvest’ [8, 27]

 ‑ TCPs, services and programs that harm patients, diminish health outcomes, impair health care delivery, increase costs unnecessarily or result in organisational waste should be removed, reduced or restricted to address these adverse outcomes.

 ‑ If there are opportunities to replace TCPs, services and programs that are safe, effective and cost-effective with others that offer greater advantage no explanation is needed other than the expected benefit.

 ‑ If budgets are cut or funding is required for high priority activities it is worth remembering that health service staff place a high value on transparency and are disillusioned by attempts to disguise cost reduction methods.

▪ Do not develop ‘disinvestment’ as a health improvement strategy or research domain [8, 27].

▪ Expand existing healthcare improvement paradigms and research domains (eg EBP, health technology assessment, guideline development, implementation science, knowledge translation, quality improvement, system redesign, health economics, etc) to address the need for theories, frameworks, methods and tools for [8, 23, 24, 26–30]:

 ‑ systematic and proactive identification of harmful, ineffective and inefficient TCPs, services and programs

 ‑ implementation of interventions to remove, reduce or restrict TCPs, services and programs

 ‑ evaluation of the process, impact and outcomes of these changes

 ‑ measurement of savings if possible

 ‑ reallocation of resources if appropriate

▪ The principles for a rigorous, evidence-based approach to decision-making for disinvestment in the context of all resource allocation decisions are incorporated into the Framework for an organisation-wide approach to disinvestment in the local healthcare setting (Figure 5)

Disinvestment in the local health service setting – key messages

▪ Decisions to proceed with a project to implement change are often made without consideration of research evidence and local data and are not well-defined in terms of the intervention, practitioner group, patient population, indications, etc.

 ‑ Clinicians are frequently asked to undertake projects in their area of clinical expertise but they lack knowledge and skills in project management, implementation and evaluation.

 ‑ Clinicians are usually required to conduct a project in addition to their normal duties but without additional time or resources.

 ‑ Health service staff are well aware of their limitations and those of their colleagues in undertaking projects and they welcome advice and support.

 ‑ There are many decision-making settings and processes within health services

 ‑ There are many components in the research allocation process in addition to decision-making that need to be addressed

 ‑ There are insufficient resources and skills in decision-making, implementation and evaluation

 ‑ Staff need support

▪ Decision-making for resource allocation at the local level is not homogenous. Contrary to some assumptions in previous studies, there are multiple layers of decision-making with different actors, criteria, systems and processes. [24]

▪ There is a need for proactive methods to access and utilise high quality synthesised evidence in the research literature, routinely-collected local health service data and sources of consumer information to identify and drive disinvestment initiatives [23, 25, 30]

Disinvestment in the local health service setting – recommendations

▪ Introduce a framework for an organisation-wide approach to disinvestment underpinned by evidence-based principles [30]

▪ Focus on optimising health care and using resource effectively rather than cost-cutting

▪ Implement systematic, transparent, evidence-based methods that integrate with, or build upon, existing decision-making systems and processes to identify TCPs that should be removed, reduced or restricted. [23, 30]

▪ Consider settings for decisions about both monetary (eg capital procurement and clinical purchasing) and non-monetary (eg development and authorisation of guidelines and protocols that stipulate use of drugs or equipment, recommend diagnostic tests, specify referral mechanisms etc) resources as opportunities to identify TCPs that should be removed, reduced or restricted. [23, 26, 27, 30]

▪ If seeking opportunities to save money by removing, reducing or restricting TCPs, use a systematic transparent process rather than ad hoc nominations from individuals. [8, 27]

▪ Ensure that proposals are fully developed before making decisions to proceed including consideration of research evidence and local data to determine the nature and scope of the problem and the most effective solution; clarification of the intervention and scope of the project in terms of practitioner group, patient population, indications, etc; and assessment of feasibility, risk and cost of implementation and evaluation. [28]

▪ Ensure appropriate knowledge and skills and adequate resources are available for effective project design, management and governance; implementation and evaluation

▪ Integrate activities to remove, reduce or restrict TCPs within the language and methods and tools of familiar health service improvement paradigms such as EBP, quality improvement and system redesign rather than the construct of ‘disinvestment’. [8, 24, 30]

▪ Include appropriate stakeholder consultation and involvement in making, implementing and evaluating decisions to disinvest. [25, 30]

▪ Develop mechanisms to receive and act upon consumer or community-initiated feedback on resource allocation decisions. [25]