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BMC Health Services Research

, 10:288

First Online: 14 October 2010Received: 07 April 2010Accepted: 14 October 2010DOI: 10.1186-1472-6963-10-288

Cite this article as: Mortimer, D. BMC Health Serv Res 2010 10: 288. doi:10.1186-1472-6963-10-288


BackgroundRemarkable progress has been made over the past 40 years in developing rational, evidence-based mechanisms for the allocation of health resources. Much of this progress has centred on mechanisms for commissioning new medical devices and pharmaceuticals. The attention of fund-managers and policy-makers is only now turning towards development of mechanisms for decommissioning, disinvesting or redeploying resources from currently funded interventions. While Programme Budgeting and Marginal Analysis would seem well-suited to this purpose, past applications include both successes and failures in achieving disinvestment and resource release.

DiscussionDrawing on recent successes-failures in achieving disinvestment and resource release via PBMA, this paper identifies four barriers-enablers to disinvestment via PBMA: i specification of the budget constraint, ii scope of the programme budget, iii composition and role of the advisory group, and iv incentives for-against contributing to a -shift list- of options for disinvestment and resource release. A number of modifications to the PBMA process are then proposed with the aim of reorienting PBMA towards disinvestment.

SummaryThe reoriented model is differentiated by four features: i hard budget constraint with budgetary pressure; ii programme budgets with broad scope but specific investment proposals linked to disinvestment proposals with similar input requirements; iii advisory-working groups that include equal representation of sectional interests plus additional members with responsibility for advocating in favour of disinvestment, iv -shift lists- populated and developed prior to -wish lists- and investment proposals linked to disinvestment proposals within a relatively narrow budget area. While the argument and evidence presented here suggest that the reoriented model will facilitate disinvestment and resource release, this remains an empirical question. Likewise, further research will be required to determine whether or not the re-oriented model sacrifices feasibility and acceptability to obtain its hypothesised greater emphasis on disinvestment.

List of abbreviations usedCAMHSChild and Adolescent Mental Health Services

MMAMacro Marginal Analysis

MRHAMidland Region Health Authority

NICENational Institute for Health and Clinical Excellence

PBMAProgramme Budgeting and Marginal Analysis

PCTPrimary Care Trust

SRHASouthern Region Health Authority.

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Autor: Duncan Mortimer


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