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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

â–ª How can a systematic evidence-based approach to disinvestment be implemented in a healthcare organisation?

â–ª 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

â–ª What are the relevant organisational change mechanisms?

â–ª What does leadership for disinvestment involve?

Decision-makers

â–ª Who has the authority, and the will, to make and act upon decisions about disinvestment?

â–ª 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

â–ª How does the relevant information get to them?

â–ª What other agendas do they bring to the decision-making table?

â–ª Who has the time, relevant skills and adequate resources to identify, implement and evaluate the required practice changes?

Decision-making

â–ª Are all viewpoints equal?

â–ª What criteria should be applied to disinvestment decisions and prioritisation?

â–ª What is the nature and source of information required?

â–ª How do decision-makers become aware of the need to disinvest certain practices?

â–ª How are policies and guidance documents used by local decision-makers to allocate resources?

Assumptions

â–ª 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

â–ª 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?

â–ª What are the rights and responsibilities of stakeholders?

▪ Different stakeholder views of what is meant by ‘little or no health benefit’

â–ª What is the effect of culture on disinvestment? (authoritative versus consultative, transparent versus hidden)

â–ª What are the motives and incentives for disinvestment?

Financial and commercial

â–ª What funding is required for disinvestment initiatives and where can it be found?

â–ª How can the difficulties inherent in the complex funding arrangements within health services be overcome?

â–ª How can savings be measured?

â–ª How can savings be reinvested?

Values and ethics

â–ª How can transparency of process be ensured?

▪ What is a ‘fair and reasonable’ process?

â–ª What are the access, equity and legal considerations?

â–ª What is the best way to deal with conflict of interest with commercial entities?

Research and evaluation

â–ª What effect will the limited evidence base for some practices have on the process?

â–ª How can the lack of tested methods for implementation and evaluation be addressed?