Disinvestment in health care

Four linked BMJ articles consider disinvestment in health care.1 2 3 4 They suggest several ways in which disinvestment can be promoted, including better evidence based clinical decision making; better alignment of health services between primary and secondary care providers; better integration of the health system with the social care system and community care; new technology; a culture of collaboration rather than competition; a better managed system of skill development; changes in working practice; the empowerment of patients; reductions in administrative costs; and greater dialogue to promote knowledge and understanding, so that policy options can be better discussed and agreed between relevant stakeholders. All of these are valuable insights into possible actions to promote change. However, they tend to underestimate the factors that promote resistance to the kinds of change a strategy of disinvestment is bound to cause.

Sociological and psychological research indicates why disinvestment is likely to meet resistance. Sociologists emphasise the contested problem of managerial control and how institutions tend to change only when a major shift in the nature of control occurs and a new management model is generally accepted.5 Psychologists emphasise resistance to change as a cognitive and emotional response at the individual and group level. We cling to what we know. Indeed, it seems natural to resist change, and it would be unexpected if major change was enthusiastically embraced.6 Studies of resistance to change imply that for change to happen managers need to be skilled in aligning individuals, groups, and stakeholders in terms of promoting more ways of framing contentious matters and they must tackle the problems of irrational thought processes.7 In the complex environment of health care, managing change requires skilful management at several levels, including leadership, culture (organisational and local), teams, and technology.8 In public sector change generally, we need to do better at engaging the front line in policy making.9 10

Studies of healthcare disinvestment identify five key challenges in managing disinvestment: lack of resources to support policy development; lack of agreement about comparative cost effectiveness within and between disciplines; political, clinical, and social resistance to removing an existing technology or practice; disputes over evidence; and lack of research into disinvestment as a policy option and practice.11 12 Discussions in this area have tended to focus on economic outcomes, but in these debates—for example, in relation to decisions by the National Institute for Health and Clinical Excellence about clinical effectiveness—we lack “national champions” of what needs to be “displaced” to fund new treatments.13 As a result, the debate has tended to remain fragmented, with little shared agreement on what needs to be done.

We lack a shared common language, a vocabulary, and a narrative of change for discussing the subject. Without this, an integrated policy of disinvestment will be difficult to introduce. Indeed, the very term “disinvestment” is problematic because for many it suggests reduced investment and divestment. It runs the risk of being associated only with cost reduction strategies, rather than with a coordinated policy of maximising the returns of investment in health care. We shouldn’t be looking only to cut things but to ensure that funding is focused on healthcare interventions and technologies that optimise health outcomes, individually and collectively.

To set a positive agenda of disinvestment, we need to convince healthcare professionals and the users of services that it can be an important means of freeing up resources, thereby improving the efficiency and the quality of health care. This will require a coordinated dialogue between healthcare managers and healthcare professionals to determine how a systematic, policy based approach to disinvestment is managed.