Accelerating the adoption and diffusion of disinvestment initiatives: is a NICE way the right way?

Abstract

BackgroundWith the NHS facing one of its toughest periods financially, most, if not all, primary care trusts (PCTs) in England have started to prioritise services and sought to identify those that are either ineffective or of low clinical value for disinvestment. Although the notion of disinvestment (withdrawal of health services from an existing health-care service that is considered to deliver little or no health gain for its cost) has an obvious logic, since the practical implementation of disinvestment decisions has proven to be both controversial and problematic. The absence of a nationally accepted list of identified procedures has resulted in PCTs developing their own approaches, with many applying different priority thresholds to different procedures. This approach has created several so-called black lists of interventions that will either not be funded or their commissioning severely curtailed. With the uptake and diffusion of disinvestment decisions often affected by a range of social, financial, professional, and institutional factors rather than clinical evidence, a postcode lottery in provision has ensued across the UK. We aimed to develop an evidence-based approach towards disinvestment, which will be piloted across the UK southwest peninsula before a national roll-out. MethodsWorking in collaboration with the National Institute for Health and Clinical Excellence (NICE) research and development team, the project used NICE's do not do (DND) database to identify topics for potential disinvestment in the NHS. Each DND recommendation was formed from a debate by the independent guideline development group, who were guided by evidence presented to them by the technical team from one of the national guideline centres, which identifies specific practices as not on balance beneficial, as unsafe, or with insufficient evidence to support its continued use. These practices are then placed on the online DND database. We identified DNDs on the basis of treatments with evidence suggesting that they are ineffective or of low clinical value from the DND database, which contains 799 records. We excluded from the study DNDs relating solely to clinical safety. Procedures were further prioritised by clinical experts in participating pilot implementation sites in the southwest peninsula, who were asked to review populated lists of DNDs to ensure: clinical soundness; practicality of implementation; and any DND of potential high effect locally. We used Hospital Episode Statistics (HES) data to collate volumes of DNDs still being undertaken in the NHS to give an estimate of overall usage and potential effect. Each DND identified was subjected to a cost analysis to provide an estimate of potential savings locally. FindingsWe identified 209 DND topics developed between 2007 and 2012 for use in the study. After local clinical prioritisation and exploration of HES data to give an estimate of usage, we identified 30 procedures for a pilot disinvestment programme solely from the NICE DND database. InterpretationThe study successfully developed an evidence-based approach towards disinvestment through the identification of ineffective and low clinical value treatments from the NICE DND database. Additional planned research that will implement the pilot list across the southwest peninsula will provide valuable information about the practical implications of disinvestment initiatives and identify any incentives or disincentives for future developments. National data will be collated before a national roll-out. FundingNational Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West.