Disinvestment of technologies and clinical practices in health services: conceptual and policy perspectives
In the context of limited health resources, health organisations must make decisions about the services that are to be funded and those that are not. Health budgets are increasingly under pressure due to the influence of a variety of factors including the funding of new technologies and clinical practices. One response to this pressure has been to explore opportunities to release funds by reducing or ceasing the delivery of certain practices or services that provide less favourable health outcomes - a process that has been referred to as 'disinvestment'.
A search strategy was developed to identify relevant publications including journal articles, technical reports and policy documents. The search terms were used to search medical databases (Ovid Medline, All EBM Reviews, EMBASE, Cochrane Library), the internet (via the Google search engine) and within guideline websites. English language publications that addressed the issue of disinvestment from a conceptual or policy perspective and any relevant guidelines, reviews or research studies were included. Identified articles which met the inclusion criteria were summarised based on content relevant to the major themes of the review.
Over 1000 potentially relevant citations, presentations and other documents were identified. The majority of these did not meet inclusion criteria. In general, the small number of relevant publications addressed the issue of disinvestment by providing a statement of the policy context, the rationale or need for disinvestment and/or a critique of existing processes.
The major themes emerging from the literature are that disinvestment relates to TCPs that are unsafe or harmful; clinically ineffective or of no or low health gain; outdated, superseded or obsolete or cost ineffective. From a policy perspective it seems that interest in disinvestment has been driven primarily from the need to release resources to fund new and emerging TCPs, Disinvestment initiatives within a health service will require careful and thorough explanation of the process and involvement of appropriate stakeholders in order to avoid negative connotations of the exercise rather than response to problems or safety issues with delivery of existing TCPs.