Tough choices are facing many health organisations, but with the right tools those unwelcome decisions can be made in a more manageable way, write Iestyn Williams and colleagues from Birmingham University’s school of social policy.

This difficult fiscal climate means commissioners need to identify services and treatment for disinvestment. Much has been made about the role of “rational” disinvestment, but stopping doing things is often a lot more difficult in practice. During previous times of economic hardship the worst affected have often been the most vulnerable in society. While efficiency savings are unavoidable, making the right decisions on the type and level of service provision is crucial.

So, with disinvestment inevitable in healthcare, what advice can we give to those embarking on such an unenviable and thankless task?


Making the case for disinvestment requires an evidence base. However, those carrying out health technology assessments have tended to focus on new interventions, leaving the raft of longer standing practices unexamined.

Increasingly there are moves to fill this evidence gap. For example, the National Institute for Health and Clinical Excellence has begun development of a “do not do” interventions database and this supports work underway in other countries.

Decision support

In the absence of published reviews of the evidence, a range of more flexible local processes are available to support decision making. For example, Department of Health programme budgeting data provides insight into current spending patterns and enables comparisons both geographically and across disease areas. Techniques such as programme budgeting and marginal analysis (PBMA) can be applied to the local disinvestment process, helping to identify candidates for service withdrawal and/or reduction.

There are many other examples of decision approaches to multi-criteria decision analysis including the widely used “Portsmouth tool”, which has been used to aid priority setting locally and may well aid decisions around disinvestment.  

Such techniques will not take the responsibility or pain out of difficult decision making, but can serve to help decision makers organise and synthesise a variety of information relevant to the decision making question.

Public engagement

If priority setting is to reflect the values of the populations served then it seems reasonable that citizens should have some say in how scarce resources are allocated.

Although public involvement in rationing decisions is a notoriously tricky and time-consuming business, the democratic and quality benefits arguably far outweigh these costs. The need to “share the pain” with the public is particularly acute when seeking to close down services.


Frameworks and methods to support decision making

  • Economic evaluation: formal evaluations of the cost-effectiveness of services and treatments (for example as produced by the National Institute for Health and Clinical Excellence).
  • Multi-criteria decision analysis: frameworks for appraising services and treatments that combine multiple considerations (for example versions of the Portsmouth tool used by many primary care trusts).
  • Programme budgeting: information (for example as provided by the Department of Health) which maps how resources are currently being spent in local areas.
  • Programme budgeting and marginal analysis: an economic approach to increasing the efficiency of spending, currently used in parts of the NHS as well as other healthcare systems.
  • The A4R framework: currently used by a number of PCTs, for example in individual funding request panels.
  • Predictive modelling: computer aided processes for identifying individuals and groups likely to incur significant care costs in the future, currently being developed by organisations including the Nuffield Trust in the UK.

Fair processes

The potential fallout from disinvestment decisions may be reduced where these decisions follow processes that are widely considered to be open and fair. Having robust and defensible decision processes is important – for example in minimising undue influence from powerful stakeholder groups.

In Setting Limits Fairly: learning to share resources for health, Norman Daniels and James Sabin propose four conditions of fair decision making processes. The publicity condition is concerned with the extent to which decision making is made accessible to the public. The relevance condition holds that decisions should only be influenced by evidence that fair minded people would consider relevant.

According to the appeals condition, there must be mechanisms for challenge and review of decisions, and the enforcement condition requires the other three conditions to be implemented and regulated.

Implementation and review

Too often lists of interventions are compiled but have no impact in practice.

In order to make genuine savings, these decisions need to be implemented and this can present a daunting challenge. Those designing local processes therefore need to ensure that decision making bodies are granted sufficient clout for the exercise to be worthwhile; a clear link to finance functions and a commitment to governance, management and review to ensure that disinvestments are actually carried out.


Aligning each of these dimensions requires effective management and leadership. If resource scarcity presents a “wicked” problem, one where simple solutions are not available, there is a requirement for a flexible and consultative leadership style in response.

For example, to be successful, disinvestment processes will need to convince sceptical stakeholders of the need for unpleasant decisions. These dimensions of trust, relationships and legitimacy are harder to pin down, but no less important than questions of evidence, engagement and process.

To date priority setters have focused heavily on process which means there are a number of helpful tools and processes which commissioners can draw on to help. While these tools can be an important facilitator they need to be understood and managed well – equally the focus on process is only half the battle. Defensible processes, high profile engagement and skills in political coalition building will therefore be important in ensuring the enterprise is not undermined.

In addition, the complexity of the NHS means that putting decisions into practice will require the full range of governance and implementation levers to be employed so that informed decisions on the allocation of scarce resources can be put to effect.

Why strong leadership is essential

Disinvestment processes require strong leadership at all stages and not least to convince sceptical stakeholders of the need for unpleasant choices to be made. The dimensions of trust, relationships and legitimacy are harder to pin down but no less important than questions of evidence, engagement and process

Decision making

  • Strong evidence base: it is difficult to make disinvestment decisions without evidence to demonstrate that services are ineffective or resources would be better used elsewhere.
  • Decision support tools: a number of multi-criteria decision analysis tools have been developed and programme budgeting and marginal analysis can help in identifying candidates for service withdrawal and/or reduction.
  • Skills: it is imperative that decision makers can call on expertise and capability to interpret information.
  • Public engagement: high profile, deliberative public involvement can help gain support and acceptance for disinvestment decisions as well as raising awareness of the challenges the NHS faces.


  • Disinvestment does not start and finish with decision making.  In order to have a real impact on budgets, decisions need to be implemented and this alone can present a daunting challenge. 
  • The legitimacy and authority of decision making bodies needs to be sufficient to ensure that decisions are implemented.
  • Clear commitment to governance, management and review to ensure that disinvestments are actually carried out in practice is required.


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