Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting

Initial interviews and workshops with key stakeholders identified that systems and processes for purchasing drugs and clinical consumables and capital procurement for building and equipment were potential methods for systematic identification of disinvestment opportunities. Methods to encourage those making decisions about expenditure to consider disinvestment could be integrated into current processes. Prompts, triggers and even mandatory requirements to consider disinvestment could be included in algorithms, protocols, checklists, specific directions within purchase orders, explicit decision-making criteria for committees, or steps in application processes that require authorisation. Incorporating considerations for disinvestment into existing decision-making infrastructure might be achieved quickly and, once established, delivered with no additional costs.

Interviews with staff and analysis of health service documents found that Monash Health had very clear procedures for purchasing but less clear processes for capital expenditure. Only one prompt to consider disinvestment was identified in the wide range of decision-making contexts investigated. The application form for introduction of new TCPs asked applicants to identify current practices that could be discontinued when the new TCP was introduced.

Meetings were held with procurement staff to discuss evidence-based resource allocation processes and consideration of disinvestment. Positive outcomes included participation of the Procurement Manager in the Technology/Clinical Practice Committee (TCPC) meetings regarding introduction of new TCPs, clarification of authorisation processes for new equipment or consumables prior to purchase, and inclusion of a CCE staff member on the Clinical Purchasing Committee to facilitate evidence-based decision-making. However no changes regarding identification of opportunities for disinvestment were implemented. The Purchasing Policy Guidelines were due for routine review and those responsible welcomed participation of the SHARE team to address these issues; however the review was not undertaken during the life of the SHARE Program.

There are discussions in the current literature about smart, innovative and evidence-based purchasing [41, 42] and the need to consider economic evaluations in purchasing decisions [43], but we were unable to find mention of purchasing or procurement processes being used to identify local disinvestment opportunities.

In addition to processes that allocate funding, systematic mechanisms for allocating non-monetary resources were also recognised by repondents as potential methods to identify disinvestment opportunities. Local guidelines and protocols determine allocation of resources for specific conditions, patient groups or clinical procedures by stipulating use of drugs or equipment, recommending diagnostic tests, selecting health professional groups, prioritising staff time, specifying referral mechanisms and allocating capacity in clinics, operating rooms and other facilities. There are potential opportunities for disinvestment in all of these activities. Prompts, triggers and mandatory requirements to consider disinvestment could be introduced into document development and authorisation processes. Requirements for local guidance to be based on the best available evidence would ensure that harmful, ineffective or inefficient TCPs would be identified in the systematic review process and steps to discontinue these practices could be included in the resulting guidance document. Evaluation, audit and review of guidelines and protocols may also identify opportunities for disinvestment. Mechanisms involving local guidelines and protocols could be implemented quickly and, once established, delivered with no additional costs.

The CCE staff members involved in SHARE were simultaneously developing a new Policy and Procedure Framework for Monash Health. No examples of using local guideline and protocol development to identify disinvestment opportunities were identified from the literature or local consultations in this process.

A prompt to consider whether any current practices could be discontinued was included in the instructions to developers of guidance documents. “If the procedure involves introduction of new practices, identify the current practices that are being replaced. Cessation or restriction of specific activities in current practice must be addressed with active interventions in the same way as introduction of new practices.” [44]. A requirement that a systematic review process was followed and a checklist recording the steps undertaken were also included.

After developing the new framework, CCE staff handed it over to the department that had responsibility for organisational documents for implementation and ongoing governance. The disinvestment prompts and requirement for systematic reviews, along with other instructions, were removed by the implementers with the intention of making the process less onerous for document developers.

Several authors refer to the potential to use guidelines for implementation of disinvestment recommendations [45‐49] but we have not found any discussion of local guideline and protocol development being used as a method to identify disinvestment opportunities.

Scoping searches of the health databases in preparation for the literature review revealed a growing body of evidence about practices that are harmful, of little or no clinical benefit, or where a more effective or cost-effective alternative is available. Searches for evidence-based disinvestment opportunities could be undertaken and the findings delivered directly to decision-makers. Workshops with the Steering Committee determined that to avoid wasting time and resources considering information that does not represent the best available evidence, only high quality synthesised information such as systematic reviews, health technology assessments and evidence-based guidelines should be used proactively to drive decisions.

It was clear from interviews with decision-makers that Monash Health had no mechanisms to use research evidence proactively. The SHARE team developed a catalogue of disinvestment opportunities to enable this (Additional file 1: Table B). Searches were undertaken in known sources of high quality synthesised evidence to identify TCPs which were demonstrated to be unsafe, not effective or not cost-effective [50‐54]. This was supplemented with information from evidence-based publications specifically focusing on disinvestment [55, 56]. A taxonomy was developed to classify publications by Bibliographic Source, Type of technology/practice, Disease group, Age, Gender, Healthcare setting, Professional group, Specialty, Outcomes, Author’s recommendations and Links to original documents. Classifications were based on existing definitions from the National Library of Medicine Medical Subject Headings (MeSH) [57]; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) [58]; McMaster Evidence Updates [59]; and Academy Health Glossary of Terms Commonly Used in Health Care [60]. When suitable definitions were unavailable, additional classifications were created and defined to meet Monash Health needs. Potential disinvestment targets were also captured opportunistically by SHARE participants from conferences, journal articles, email bulletins and awareness of practice elsewhere. The project team reviewed research evidence to validate the claims and, if appropriate, add them to the catalogue, bringing the total to 184 TCPs. An algorithm for identifying disinvestment projects from a catalogue of potential TCPs was developed, based on an algorithm previously developed for introduction of new TCPs [2]. To prevent unnecessary resource use, the information is requested in stages, each stage predicated on a positive decision at the stage before (Fig. 5). To minimise the impact on busy clinicians and managers, work that does not require high level skills is undertaken by a project officer. To facilitate objective and trustworthy decisions, work that does require high level skills is undertaken by independent experts proficient in evidence appraisal and analysis of health service data, and transparent criteria are used in deliberation. Local information from policies and procedures, in-house knowledge and experience regarding applicability, and routinely-collected health service utilisation data, are used to inform the decision to proceed with a disinvestment project.

The concept of a catalogue of disinvestment opportunities has been discussed widely in the literature under the more recently coined term ‘low value’ lists. Lists are being developed by governments and health agencies [55, 61, 62], commissioners of health services [63], professional bodies [47, 64, 65] and researchers [66‐68]. Some of these lists are derived from research evidence, some are based on expert opinion and others from a combination of the two. Although removing practices of little or no value clearly has merit, the definition of ‘low value’ is not always explicit and the validity and appropriateness of some of the lists and the ethics of their application have been questioned [67, 69‐73]. Duckett and colleagues separate them into ‘top down’ and ‘bottom up’ approaches, noting that each has benefits and drawbacks [74]. The ‘top down’ approaches, such as the UK National Institute for Health and Clinical Excellence ‘Do Not Do’ Recommendations [55], are described as providing the most consistent, objective, transparent and relevant evaluations. The ‘bottom up’ approaches, such as the Choosing Wisely program being replicated in national campaigns across the world [75], highlight potentially ‘low value’ treatments and tests so that clinicians and consumers can consider the relative benefits in their specific situations. Potential users of ‘low value’ lists may wish to confirm the basis for claims made, in particular the definition being used and the use of systematic review evidence in the inclusion process.

Respondents in the interviews and workshops to identify potential settings and methods for disinvestment noted that hospitals and other health facilities routinely collect large amounts of data. Three approaches to targeted analysis of routinely-collected data to discover opportunities for disinvestment were identified.

Interviews with Monash Health decision-makers found that they often used local data to understand problems or develop solutions, but they did not use it proactively to review current practice, seek opportunities for improvement or drive priority setting. While Monash Health was reported to be very responsive to incident reports and complaints on an individual case basis, there were no processes to consider this body of data, seek out patterns or identify areas of concern for further action.

The first two approaches were to be explored within the activities of the proposed Data Service (Aim 3 Fig. 1), but unfortunately this could not be established, mainly due to limited staff capacity and problems with local data access and coordination [15]. The third approach was to be considered in a consumer engagement framework [40], however the incident reporting software and consumer information available from other sources was thought to be inadequate for aggregation and meaningful interpretation, problems that have since been resolved but which prevented exploration at the time. Due to these local barriers, proactive use of health service data was not employed to identify disinvestment targets for pilot projects.

There is a large body of literature on examination of practice variation [76]. Two recent studies have used practice variation in national and regional settings specifically to identify ineffective practices and note the potential to do so within local health services, or for health services to benchmark against their counterparts [21, 74]. Hollingworth et al. note that many procedures with the highest variability are often not on the ‘low value lists’, indicating additional possibilities to identify disinvestment opportunities from this approach [21]. Use of local data clearly has potential but problems with data validity, reliability, comprehensiveness and degree of sensitivity to disinvestment requirements remain significant barriers [5, 7, 21, 48, 77, 78]. In the same way that the algorithm described above uses local data to substantiate a decision to disinvest a TCP arising from research evidence, research evidence would inform a decision arising from local data by identifying best practice in the relevant area and confirming whether change is needed and what the appropriate alternatives are [38].

The literature review exploring the concepts and implications of disinvestment in a local health service found that economic approaches had been used to identify disinvestment opportunities and had potential to do so at Monash Health. Priority setting exercises use economic principles to determine which practices, programs or services to introduce, maintain or remove. Decision-makers weigh up options for investment and disinvestment and select their preferred alternatives using pre-determined criteria established by the stakeholders.

Local respondents were not familiar with health economic methods for priority setting. The subsequent literature review focused on identifying examples of economic methods found two existing reviews that analysed and compared priority setting exercises [79, 80]. Four methods met the criteria of economic analysis applicable at the local health service level; however all of these have limitations in their ability to identify disinvestment opportunities in this context. Health Sector Wide (HsW) Priority Setting, Quality Adjusted Life Year (QALY) league tables and Generalised Cost-Effectiveness Analysis (GCEA) rely on economic evaluation data, making them unsuitable for decisions involving TCPs which do not have any available published economic evaluations [80‐82]. GCEA is generally used to make shifts within departmental budgets, rather than across departments or programs [82], also limiting application in the local setting. HsW is designed to shift the focus away from program budgets towards well-defined target populations with particular health problems [81], however health service funding allocation is not based on condition-specific populations. Program Budgeting and Marginal Analysis (PBMA) is the most widely used method; the process is well-tested and guidance is available [79, 83]. It applies the principles of opportunity cost and marginal analysis to determine priorities for health program budgets in the context of limited resources [84]. PBMA has been proposed as a method of ‘rational disinvestment’ [85].

These findings were summarised in a discussion paper and debated at a workshop with the SHARE Steering Committee. Although a health economist had been engaged as a consultant to the SHARE Program, Monash Health had no plans to establish in-house expertise in health economics. The lack of ongoing health economics capability was the key factor in the decision that priority setting exercises were not feasible at Monash Health.

Although decision-makers acknowledge the usefulness of PBMA, it remains quite difficult to achieve in practice [5, 77, 84]. The major limitations for all priority setting approaches include lack of standardisation in cost-accounting, lack of sufficient high quality data to inform decision-making, and lack of time and skills to undertake the process and implement the decisions [5, 9, 77, 78, 83‐85].

The early scoping searches of the health literature also identified system redesign as another potential method. It is a familiar process in health services and offers a well-accepted context to introduce practice change. System redesign describes a range of methods and tools that have been adapted for use in health care including Lean thinking [86], Clinical process redesign [87], Program Logic mapping [88], Plan Do Study Act quality cycle [89] and Failure Mode Effect Analysis [90]. System redesign could be integrated into a systematic organisational approach to disinvestment.

Information was gathered from another focused literature review to identify examples of system redesign, methods, tools and resources required; and from interviews to investigate system redesign within Monash Health. The literature review was unable to identify examples of system redesign that specifically related to resource allocation decisions for TCPs and, although there was extensive expertise in system redesign at Monash Health, none of the respondents could recall any projects driven by decisions related to resource allocation. However, some of the reported reasons and motivation for system redesign are consistent with principles of disinvestment, for example better use of existing resources, maximising value and eliminating waste, increasing efficiency and reducing duplication of services [91‐93]. Monash Health respondents noted that, although disinvestment is not usually an aim of redesign processes, it may be an outcome.

These findings were summarised in a discussion paper and debated at a workshop with the SHARE Steering Committee. The committee decided that system redesign methods would not be used specifically to identify opportunities for disinvestment, but they may be useful in implementing decisions to disinvest and this should be considered for future projects.

The potential for system redesign as a useful approach to implementing disinvestment has been confirmed in more recent literature [9, 18, 62] and also suggested as a method to quantify disinvestment [62]. Applying the terminology of ‘system redesign’ has also been advocated as a strategy to increase the likelihood of implementation by avoiding the negative connotations of the word ‘disinvestment’ [18, 94].

A method of rapidly identifying disinvestment opportunities for pilot projects was needed. The Steering Committee proposed that an Expression of Interest (EOI) process where health service staff nominated their own projects could potentially provide quick results.

Monash Health staff were invited to submit applications to receive training and support from the SHARE Program for a disinvestment project. An EOI form was drafted to include criteria agreed by the SHARE Steering Committee. To facilitate completion of the new document, the content and format of existing Monash Health templates familiar to the applicants were adapted to address the EOI requirements. A disinvestment project was defined as one that removes a TCP that is unsafe or ineffective, restricts a TCP to more appropriate patient groups, or replaces a TCP with an equally safe and effective but more cost-effective option. Training in implementation and evaluation methods was provided by the Capacity Building Service. Support available from the Project Support Service included administration; project planning and implementation advice including analysis of barriers and enablers; evaluation advice including establishing systems to monitor and evaluate change and identify sources of data; and economic evaluation or cost comparison study (methodology determined by SHARE health economist). Clinical trials and projects already underway were excluded.

Invitations to submit an EOI were distributed via the Clinical Program Directors. Two applications were received.

Three more-recently published frameworks for disinvestment also propose applications from stakeholders in the identification process [95‐97]; however the effectiveness of this approach has not been established [21, 98].

Including the two EOIs, 19 TCPs were investigated as potential pilot disinvestment projects. The nature of the change and reason for nomination are summarised in Table 3.

Proposals based on individual’s observations or local knowledge have been referred to as “soft intelligence” [21]; this has been described in attempts at disinvestment by others and noted to be unsustainable [21, 23, 99].

The priority setting exercises described above clearly include a prioritisation process, however initiatives that identify disinvestment targets by other means may need a specific prioritisation process to choose between the available options.

A literature review to identify frameworks and tools for prioritisation found a Spanish guideline and assessment tool specifically for disinvestment [100], a framework for priority setting in the Australian context [101, 102], a guidance document for prioritisation of new or existing technologies [103], and two systematic reviews and an overview of international practice in prioritisation of new technologies [104‐106]. Consultation with local informants identified that replacement of high cost medical equipment had to meet the requirements of the state government Medical Equipment Asset Management Framework (MEAMF). Interviews with local decision-makers identified that there were no decision-making settings at Monash Health where disinvestment was explicitly considered, hence nowhere to pilot prioritisation tools. The Steering Committee directed the SHARE team to develop a tool that could apply to both investment and disinvestment and pilot it in the annual capital expenditure funding round.

The Australian priority setting framework [101, 102] was adapted for use as a local template and the Spanish PriTec prioritisation tool [100] was modified to address MEAMF requirements and include relevant elements from the TCPC application forms [2]. Equivalent criteria for comparison of non-clinical technologies such as information technology and building works were developed as they are considered alongside health technologies in the capital expenditure process. The tool included methods of establishing criteria, a suite of domains from which criteria could be selected, potential questions that can be asked within each domain, scoring systems, processes for weighting criteria and a template to record decisions. These were workshopped with the Steering Committee and members of the Capital Expenditure Committee and refined based on their feedback. The tool was not tested; the capital expenditure process was cancelled in that year as Monash Health had no spare capital.

Subsequently, lists of criteria for consideration in prioritisation and decision-making have been published for disinvestment [22, 107‐110], resource allocation [111, 112] and general decision-making [113], and software applications are now available to facilitate prioritisation processes [83, 114]. Other more recent publications have noted that, like Monash Health, most decision-makers use their own prioritisation matrix based on simple spreadsheets or business case templates and that this variety of tools makes it difficult to compare costs and outcomes within and between agencies [9, 77, 94].

Prioritisation tools primarily focus on characteristics intrinsic to the TCP. However additional criteria may influence whether a TCP is selected to be the focus of a practice change initiative. These might be factors that affect the outcome of a project such as likelihood of success or sustainability and potential usefulness of the evaluation, or pragmatic features that enhance initiatives chosen specifically as pilot or demonstration projects such as opportunities for ‘quick wins’.

Criteria for the EOI process were developed based on information from the literature and stakeholder consultations, and refined in consultation with the SHARE Steering Committee. The EOI criteria stipulated that the project must be based on high-quality evidence, be endorsed by Program and Department Heads, have appropriate resources allocated to undertake the project, have a documented clinical pathway and clear measurable outcomes. These and additional criteria that emerged in general discussion during SHARE meetings are outlined in Table 4. However no explicit decision-making criteria were established to prioritise or make final decisions regarding pilot projects.

The decisions made were pragmatic, based on likelihood of ‘quick wins’ and unspecified factors related to the proposed TCP. Prioritisation did occur, but the reasoning was not transparent. The final outcomes and reasons for the decisions are summarised in Table 3. Of the 19 proposed TCPs, four were not investigated as the Steering Committee directed the SHARE team to disregard them in favour of subsequent proposals which were thought to have greater potential; two had incomplete investigations for the same reason; and nine were rejected for a range of issues. Four applications were accepted. The first was withdrawn almost immediately by the clinical project leaders who became aware of additional evidence that reduced their confidence in the original decision and elected to undertake a randomised controlled trial (RCT) instead. The second had moved into the development and planning phase when the clinical project leaders initially questioned the evidence underpinning the guideline recommendation they were implementing, and subsequently decided that the practice to be disinvested was not routinely performed at Monash Health. The third had potential as a disinvestment activity but was not well defined. The SHARE team worked with the clinical project leaders to identify and quantify the problem and clarify the proposed practice change; however the project was withdrawn when it became clear that external factors would prevent it from being achieved within the original SHARE timelines (this decision was made prior to reduction of funding in the final year of the program). The fourth project went ahead. Two of the four projects accepted were from the EOI process and the other two had external funding from the Victorian Policy Advisory Committee on Technology (VPACT). VPACT funding was provided to implement new technologies, however both projects had an element of disinvestment as the new TCPs were replacing a clearly identified current practice.

Deciding between several alternatives can be a complex process requiring consideration of multiple factors. This has been addressed in more recently developed tools. Multi-criteria decision analysis (MCDA) allows consideration of all factors simultaneously [115, 116] and Accountability for Reasonableness (A4R) is based on four principles ensuring that decisions are relevant, transparent and able to be enforced and appealed [117]. MCDA is the foundation for the Star model (socio-technical allocation of resources) [118‐120] and the EVIDEM framework (Evidence and Value: Impact on DEcision Making) [121]; both of which have been piloted, revised and produced resources to aid implementation. A4R is the basis for the 6-STEPPPs tool (Systematic Tool for Evaluating Pharmaceutical Products for Public Funding Decisions) [122] and A4R and MCDA have been combined in other decision-making applications [115, 123].

The challenges in identifying suitable disinvestment projects are well documented. Decision-makers find it difficult to identify appropriate disinvestment opportunities [5], even when provided with evidence-based lists of appropriate options [48, 134]. Having made a decision, they are often uncertain about whether it is correct [5] and some prefer to avoid the decision and “invest to save” as an alternative to disinvestment [18]. Decision-makers can be enthusiastic supporters of disinvestment in theory, but unable to select TCPs for disinvestment in practice [21].

The absence of standardised methods for disinvestment decision-making is well-recognised [11, 18, 19, 23, 99]. Lack of transparency was reported in the earlier explorations of decision-making at Monash Health [39] and is also discussed in the literature in relation to disinvestment processes [7, 23, 62, 77, 83, 99, 135].

Ad hoc approaches to disinvestment decisions have been reported as “non-sustainable, reliant on chance or not conducive to independently identifying local opportunities for disinvestment” [21], compromising transparency and leading to uncertainty [23]. The gap between rhetoric and reality is described as the heart of the challenge related to disinvestment in healthcare policy and practice [99]. The experience that “a lot of decisions are taken on gut feeling” and the problematic “tendency to adopt a short term perspective whilst searching for a ‘quick fix’ instead of taking a whole systems perspective based on consideration of long-term sustainability” [99] reflects the SHARE experience.

SHARE had all the recognised enablers to systematic use of synthesised evidence in decision-making [136‐140]. The decision-makers understood the usefulness of systematic reviews, the program was committed to EBP, and the organisational culture was supportive. The CCE team had the appropriate skills and were sufficiently resourced to identify and access the evidence, ensure its applicability, highlight the relevant message and deliver it directly to decision-makers. Yet the planned systematic approach using synthesised evidence was not followed. The shortened timelines prevented exploration of the reasons for this unexpected outcome.

The non-systematic approach also led to a lack of transparency. All discussions were documented in minutes of the meetings and there were no attempts to be covert, however in the absence of a specified process and explicit criteria, it was not always clear how decisions had been made. The decisions themselves were transparent but the methods to reach them were not.

“Understanding how the technology got on the agenda, where it came from and who was pushing for it” have been reported as important factors for senior health decision-makers [135]. When invited to nominate candidates for disinvestment, clinicians frequently identified the practices of other professional groups rather than their own [21, 70].

This is also true of the SHARE process. Eight proposals were made by people who had no connection with the TCP pathway. In addition, two were proposed because they were proceeding anyway (Therapeutic Equivalence Program) and two were proposed by the state health department unit (VPACT) providing funding to implement new TCPs (Table 3). In total, 12 were proposed by ‘outsiders’. Five proposers were participants in the TCP pathway but were not the clinicians whose practice was nominated for change. Only three nominations were made by the potential adopters; one was the pilot project accepted and implemented, one was accepted as a pilot project but was subsequently withdrawn by the applicants and the other was nominated too late to be included in the SHARE timeframe.

Noted barriers to EBP include lack of authority to make the change [78, 84, 137, 139‐142] and lack of ownership by key stakeholders [84, 143‐145].

Most of the SHARE activities were either within the remit of CCE or the portfolios of the executives and senior managers on the Steering Committee. However the SHARE team did not have ownership of the data services, purchasing and procurement processes, and guideline and protocol documentation, or authority to make decisions in these departments. Although managers in these areas were generally supportive, their heavy workloads and competing priorities unrelated to SHARE activities prevented successful implementation of change in these areas.

Disinvestment has been associated with a perceived focus on ‘cost cutting’ and ‘taking away’ in preference to ‘evidence-based care’ [21, 23, 62, 146], even to the extent that alternative terms have been introduced to avoid this [18, 62]. Improving the quality of care while reducing costs is one of the key arguments for ‘value for money’ achieved through disinvestment, highlighting the tension created by the implication that health services can deliver better care while saving money [48, 62, 134, 147‐149].

Monash Health staff also perceived that “financial drivers were stronger than clinical drivers” in previous decision-making processes (Table 1).

In contrast, this was not a notable feature in the SHARE process. Only two projects were explicitly initiated to save money; the Therapeutic Equivalence process aimed to replace high cost drugs with lower cost but equally effective alternatives. These projects were included as potential pilot projects as they were already going ahead. All nominations arising directly from the SHARE process related to safety and effectiveness of the drugs, clinical procedures or diagnostic tests proposed for disinvestment. In five cases, cost-savings to the hospital and/or patients was noted as a secondary outcome arising from reduced adverse events or improved patient outcomes. Although disinvestment of most of the proposed TCPs was likely to result in cost-savings this was not mentioned as a priority in the nomination or decision-making processes.

Eleven proposals were to reduce use of a TCP, six were to replace an existing TCP with a better alternative, one was to restrict practice in a defined patient population and one was to cease practice altogether. Seven proposals were for inappropriate or overuse of diagnostic tests.

Clarity of aims and objectives and a clear proposal for change are significant factors in successful disinvestment [99].

Lack of clarity in the proposal for change is the reason that proposed TCPs did not proceed to guidance for disinvestment; specific issues include insufficient information on the population, intervention, comparators and outcomes; harms and benefits not clearly summarised; evidence that the intervention was effective or promising for some groups, and therefore potentially not ‘low-value’ for all patients; variation in the conclusions reached in similar scenarios; and uncertainty due to a lack of evidence, low quality or no evidence, and lack of clinical or statistical significance [134].

These findings are very similar to the SHARE experience. Only four of the proposals clearly defined the TCP, patient population, clinical indications and supporting evidence at the time of nomination. Three went on to be accepted as pilot projects and the fourth was discovered not to be applicable in the Monash Health context. Of the 13 proposals investigated, five were rejected or withdrawn due to insufficient evidence to support the proposed change (Table 3).

The pilot project was the exception, with many favourable factors in the proposal for change (Table 7). Proposals are more likely to be successful if they have certain characteristics [150‐152] and new initiatives are more likely to be sustainable if there is appropriate and adequate provision of critical factors to achieve and maintain the proposed components and activities [153]. These characteristics are summarised in the checklist for success and sustainability used in the SHARE Program [14]. The factors that make a project likely to be successful as a disinvestment initiative in a local health service are unknown, however the pilot project had many factors considered favourable by decision-makers in the SHARE Program (Table 4). In particular, there was good evidence of better patient and health service outcomes, strong local ownership and clinical champions, a ‘win-win’ scenario for adopters where nursing and allied health staff were keen to take on new procedural skills and surgeons were happy to relinquish these cases to make operating theatre time available for other patients, and surgeons were allowed to keep the theatre time and reduce their own waiting lists (rather than reallocation to other surgical specialties or closing theatres to realise savings).

Lack of knowledge and skills in project management, implementation and evaluation and lack of time to carry out the related activities are widely recognised as barriers to effective change in health care generally and resource allocation in particular [5, 7, 9, 18, 43, 77, 84, 95, 96, 124, 125, 135, 139, 154]. Dedicated resources and in-house “resource centres” have been proposed as potential solutions [9, 11, 95, 124, 125, 155, 156]. These findings were confirmed in local surveys and interviews at Monash Health [15, 39].

To address these issues, the SHARE Program implemented services to provide expertise and support to decision-makers and project teams [15]. A Capacity Building Service provided training in implementation and evaluation methods and a Project Support Service provided assistance in project management and delivery. All aspects of these support services were valued highly by participants.