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 |