Disinvestment and reinvestment in respiratory care: use of programme budgeting and marginal analysis in north Wales,UK

BackgroundRespiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Since health boards face increasing pressure to deliver services that are value for money, a programme budgeting marginal analysis (PBMA) of respiratory care was commissioned.MethodsA research group with health economics, clinical, National Health Service (NHS) finance, and pharmacy prescribing expertise was established to gather evidence on the current respiratory care pathway in north Wales and to recommend where expenditure within the service should be focussed using PBMA. A PBMA panel was established consisting of managers and directors of medicines' management, therapies, finance, planning, and health-care professionals. The review identified a budget of £86·9 million spent on respiratory care in 2012–13 for a population of 700 000. With an agreed list of criteria developed by the research team and the panel, electronic voting was used to establish criteria for decision making and vote on candidates to disinvest and reinvest in. The panel was also asked to make a set of recommendations about the allocation of funding within the respiratory service. Evidence was provided in a booklet of the potential for cost savings (from NHS finance staff) and health benefits (from a rapid review of the evidence) of the proposed recommendations to equip the panel with the notion of opportunity cost when making their investment and disinvestment decisions.Findings13 candidates were discussed; they were individual proposals for resource reallocation, ranging from specific interventions to cross agency partnership. After extensive discussion facilitated by a chairperson, four candidates received recommendations to disinvest, seven to invest, and two to maintain current activity. The panel were also able to rank the candidates in order of highest priority for the health board to lowest priority.InterpretationThis exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and reinvestment decisions. This exercise, though in its early stages, could offer further support for changes in respiratory care implementation in north Wales, if recommendations were to be implemented. PBMA also has wider implications across health agencies in the UK for resource allocation decisions, such as diabetes care.FundingNone.