Table 10 Examples of potential barriers to disinvestment
Common to all aspects of disinvestment  ▪ Lack of common terminology, theories, tested frameworks and models, proven methods and tools  ▪ The word ‘disinvestment’ generates negativity and mistrust  ▪ Divergent understanding of the concept of disinvestment between researchers and health service decision-makers  ▪ Lack of guidance and/or successful examples to follow  ▪ Lack of resources particularly time, funds and skills  ▪ Lack of any of the elements of the framework  ▪ Resistance to change |
Establishment and delivery of program  ▪ Lack of communication between agencies  ▪ Autonomy of agencies resulting in multiple different systems  ▪ Wastage of resources by duplication of effort, particularly in HTA  ▪ Lack of resources to support policy mechanisms  ▪ Lack of appropriate data collection systems  ▪ Cost of appropriate data collection systems  ▪ Lack of political, clinical, or administrative will to achieve change  ▪ Difficulty establishing systems and processes to assess choices and reallocate resources across and between programs. Easier when done within programs but this has limited effectiveness.  ▪ Difficulty establishing systems and processes between competing sectors or paradigms eg cure versus prevention, acute versus community care, drug therapy versus counselling  ▪ Lack of coordination and integration of systems and processes  ▪ Short-termism in government policy  ▪ Conflicting priorities – at individual levels, and/or between levels  ▪ System inertia  ▪ Longstanding structures, institutional practices and organisational relationships  ▪ Poor understanding of organisational practices and relationships  ▪ Lack of established triggers to initiate disinvestment discussions  ▪ Scarcity of strategic plans that include disinvestment  ▪ Lack of incentives, presence of disincentives  ▪ Fee for service models reward quantity not quality |
Stakeholder engagement  ▪ Lack of stakeholder commitment  ▪ Stakeholder inertia  ▪ Difficulty identifying and engaging multiple diverse stakeholders  ▪ Resistance to, or lack of understanding of consumer participation |
Identification of disinvestment opportunities  ▪ Health Technology Reassessment (HTR) not conducted routinely  ▪ Public and private funding focused on HTA rather than HTR  ▪ Insufficient ‘unequivocal’ evidence to disinvest  ▪ Lack of mechanisms to identify disinvestment targets  ▪ Difficulties in producing, accessing & interpreting economic data  ▪ Willingness to use lower quality evidence to maintain status quo |
Prioritisation and decision-making  ▪ Lack of knowledge of available tools  ▪ Unfamiliarity with economic evaluations  ▪ Disagreement with assumptions in economic evaluations  ▪ Difficulties estimating marginal costs  ▪ Reluctance to disinvest if there are sunk costs in existing technology and supporting capital infrastructure  ▪ Reluctance to expend effort in disinvestment if benefits not clear  ▪ Gains from disinvestment are less readily measured and may not happen but losses from disinvestment are immediate  ▪ Strength of vested interests and lobby groups  ▪ Lack of negotiating skills making it difficult to resist opposition  ▪ Conflicting priorities between decision-makers  ▪ Conflicting priorities between local, regional and national levels  ▪ Reluctance to disinvest due to heterogeneity of outcomes and/or if there is potential for benefit in some subgroups or individuals  ▪ Controversy associated with removal of an effective TCP in favour of a more cost-effective alternative and/or where there is lack of evidence of effect but general perception that it works  ▪ Sensitivity of disinvestment target eg children, cancer, end of life  ▪ Lack of decision-making processes  ▪ Lack of integration with other decision-making processes  ▪ Requirement for prospective data collection or further research to provide enough information for decision  ▪ Difficulty making choices and reallocating resources across and between programs. Easier when done within programs but this has limited effectiveness.  ▪ Difficulty making choices between competing sectors or paradigms eg cure versus prevention, acute versus community care, drug therapy versus counselling  ▪ Decision-makers not held in sufficiently high regard for decisions to be respected and enforced  ▪ Perceived influence of power imbalances and hidden agendas  ▪ Political challenges |
Implementation  ▪ Inadequate project timelines  ▪ Lack of funding for implementation  ▪ Lack of skills in project management  ▪ Lack of skills in change management  ▪ Loss of patient choice  ▪ Loss of perceived entitlement to treatment  ▪ Loss of clinical autonomy  ▪ Clinician reluctance to remove practices they perceive as integral to their professional practice and identity  ▪ Loss of perceived benefit of intervention being removed  ▪ Perceived criticism of practice and/or practitioners  ▪ Perception that management priority is only to save money  ▪ Lack of incentives, presence of disincentives  ▪ Lack of data to substantiate need  ▪ Gains from disinvestment less readily measured and may not happen, but losses from disinvestment are immediate  ▪ Complexity of practice change if disinvestment limited to certain groups or for certain indications  ▪ Lack of coordination between projects resulting in gaps and duplication  ▪ Stakeholder fatigue and disillusionment with constant change |
Monitoring and evaluation  ▪ Routinely-collected data not valid or reliable, often out-of-date  ▪ Routinely-collected data not precise or specific enough  ▪ Cost of obtaining appropriate data  ▪ Lack of post-market surveillance  ▪ Lack of methods to quantify savings  ▪ Distrust of reasons for monitoring and evaluation |
Reinvestment  ▪ Lack of methods for reallocating resources released  ▪ Lack of examples of successful reinvestment  ▪ Some cost savings may not be realised eg length of stay reduced but beds immediately filled with other patients of greater acuity |
Research  ▪ Assumptions that current practice is effective  ▪ Ethical objections to randomising patients to control groups  ▪ Resistance to enrolling patients in trials due to belief in intervention  ▪ Difficulty getting funding to research existing practices |