Rational disinvestment

With potential budget claw backs of 20% to be found in UK health care in forthcoming years, the question arises as to how these might be achieved. Based on the long-standing economic principle of marginal analysis, a framework for managing such a National Health Service credit crunch is outlined. The framework incorporates not only the natural starting point for cuts through schemes aimed at achieving the same for less cost, such as lean thinking and service redesign, but also the genuine disinvestments, in the form of stopping some services for some people, that might be required. With the International Monetary Fund wolves at the door1 and the prospect of post-election cuts in public services, where does the National Health Service (NHS) go from here? Indeed what will happen to health services worldwide as they seek to cope with unprecedented scarcity? In England, despite initiatives such as World Class Commissioning (WCC), old techniques and phrases are being trotted out as though we are in some budgetary downturn of the sort which happens from time to time. Some, such as ‘lean thinking’, simply amount to ‘squeezing more efficiency out of the system’. ‘Disinvestment’, too, is often used to refer to taking resources from areas of care that provide no added value, as though disinvestment will do no harm. Does anyone really believe that the scale of cuts required can be met by such means? Despite recent promotion of such approaches,2,3 and the elevation of the QIPP (Quality, Innovation, Productivity, and Prevention) agenda in the NHS, the evidence says that quality improvement initiatives, for example, provide very little scope for cost savings.4 A more realistic agenda has been set in two recent papers.5,6 Buried in the NHS Confederation document is the statement that opportunities to decommission infrastructure ‘as part of an agreed strategy to cease or shift service provision’ (p. 7) should be identified.5 This is in fact the almost-unspoken key. Logically, some services will have to be scaled back or stopped, either to avoid deficits or allow other services to expand, which better meet need.