Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study

Document Type : Original Article


1 Monash Health Community, Monash Health, Dandenong, VIC, Australia

2 Occupational Therapy Department, School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia

3 Department of Management and Marketing, Swinburne University of Technology, Hawthorn, VIC, Australia

4 School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia


Disinvestment from inefficient health services may be a potential solution to rising healthcare costs, but there has been poor uptake of disinvestment recommendations. This Australian study aims to understand how health professionals react when confronted with a plan to disinvest from a health service they previously provided to their patients.
This qualitative study took place prior to the disinvestment phase of a trial which removed weekend allied health services from acute hospital wards, to evaluate the effectiveness and cost effectiveness of the service. Observations and focus groups were used to collect data from 156 participants which was analysed thematically.
Initial reactions to the disinvestment were almost universally negative, with staff extremely concerned about the impact on the safety and quality of patient care and planning ways to circumvent the trial. Removal of existing services was perceived as a loss and created a direct threat to some clinicians’ professional identity. With time, discussion, and understanding of the project’s context, some staff moved towards acceptance and perceived the trial as an opportunity, particularly given the service was to be reinstated after the disinvestment.
Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.


Main Subjects

  1. Keehan SP, Cuckler GA, Sisko AM, et al. National health expenditure projections, 2014-24: spending growth faster than recent trends. Health Aff (Millwood). 2015;34(8):1407-1417. doi:10.1377/hlthaff.2015.0600
  2. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23. doi:10.1186/1743-8462-4-23
  3. Fineberg HV. Shattuck Lecture. A successful and sustainable health system--how to get there from here. N Engl J Med. 2012;366(11):1020-1027. doi:10.1056/NEJMsa1114777
  4. Elshaug AG, Hiller JE, Moss JR. Exploring policy-makers' perspectives on disinvestment from ineffective healthcare practices. Int J Technol Assess Health Care. 2008;24(1):1-9. doi:10.1017/s0266462307080014
  5. Rooshenas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL. "I won't call it rationing...": an ethnographic study of healthcare disinvestment in theory and practice. Soc Sci Med. 2015;128:273-281. doi:10.1016/j.socscimed.2015.01.020
  6. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:d4519. doi:10.1136/bmj.d4519
  7. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441
  8. Daniels T, Williams I, Robinson S, Spence K. Tackling disinvestment in health care services. The views of resource allocators in the English NHS. J Health Organ Manag. 2013;27(6):762-780. doi:10.1108/jhom-11-2012-0225
  9. Harlock J, Williams I, Robert G, Hall K, Mannion R, Brearley S. Doing more with less in health care: findings from a multi-method study of decommissioning in the English National Health Service. J Soc Policy. 2018;47(3):543-564. doi:10.1017/s0047279417000721
  10. Daniels T, Williams I, Bryan S, Mitton C, Robinson S. Involving citizens in disinvestment decisions: what do health professionals think? Findings from a multi-method study in the English NHS. Health Econ Policy Law. 2018;13(2):162-188. doi:10.1017/s1744133117000330
  11. Shoolin JS. Change management - recommendations for successful electronic medical records implementation. Appl Clin Inform. 2010;1(3):286-292. doi:10.4338/aci-2010-01-r-0001
  12. Hewitt-Taylor J. Planning successful change incorporating processes and people. Nurs Stand. 2013;27(38):35-40. doi:10.7748/ns2013.
  13. Daugird A, Spencer D. Physician reactions to the health care revolution. A grief model approach. Arch Fam Med. 1996;5(9):497-500. doi:10.1001/archfami.5.9.497
  14. Haines TP, O'Brien L, Mitchell D, et al. Study protocol for two randomized controlled trials examining the effectiveness and safety of current weekend allied health services and a new stakeholder-driven model for acute medical/surgical patients versus no weekend allied health services. Trials. 2015;16:133. doi:10.1186/s13063-015-0619-z
  15. Shaw KD, Taylor NF, Brusco NK. Physiotherapy services provided outside of business hours in Australian hospitals: a national survey. Physiother Res Int. 2013;18(2):115-123. doi:10.1002/pri.1537
  16. Campbell L, Bunston R, Colangelo S, et al. The provision of weekend physiotherapy services in tertiary-care hospitals in Canada. Physiother Can. 2010;62(4):347-354. doi:10.3138/physio.62.4.347
  17. Mitchell D, O'Brien L, Bardoel A, Haines T. Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective. BMC Health Serv Res. 2017;17(1):118. doi:10.1186/s12913-017-2035-4
  18. Brusco NK, Shields N, Taylor NF, Paratz J. A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial. Aust J Physiother. 2007;53(2):75-81. doi:10.1016/s0004-9514(07)70039-9
  19. DiSotto-Monastero M, Chen X, Fisch S, Donaghy S, Gomez M. Efficacy of 7 days per week inpatient admissions and rehabilitation therapy. Arch Phys Med Rehabil. 2012;93(12):2165-2169. doi:10.1016/j.apmr.2012.07.003
  20. Peiris CL, Shields N, Brusco NK, Watts JJ, Taylor NF. Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomized controlled trial. BMC Med. 2013;11:198. doi:10.1186/1741-7015-11-198
  21. Haines T, O'Brien L, McDermott F, et al. A novel research design can aid disinvestment from existing health technologies with uncertain effectiveness, cost-effectiveness, and/or safety. J Clin Epidemiol. 2014;67(2):144-151. doi:10.1016/j.jclinepi.2013.08.014
  22. Haines TP, Bowles KA, Mitchell D, et al. Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials. PLoS Med. 2017;14(10):e1002412. doi:10.1371/journal.pmed.1002412
  23. Wicks AC, Freeman RE. Organization studies and the new pragmatism: Positivism, anti-positivism, and the search for ethics. Organ Sci. 1998;9(2):123-140. doi:10.1287/orsc.9.2.123
  24. Braun V, Clarke V. What can "thematic analysis" offer health and wellbeing researchers? Int J Qual Stud Health Well-being. 2014;9:26152. doi:10.3402/qhw.v9.26152
  25. Kubler-Ross E. On death and dying: What the dying have to teach doctors, nurses, clergy and their own families. Taylor & Francis; 2009.
  26. Dziadzko MA, Herasevich V, Sen A, Pickering BW, Knight AM, Moreno Franco P. User perception and experience of the introduction of a novel critical care patient viewer in the ICU setting. Int J Med Inform. 2016;88:86-91. doi:10.1016/j.ijmedinf.2016.01.011
  27. Conroy SA, O'Leary-Kelly AM. Letting go and moving on: Work-related identity loss and recovery. Acad Manage Rev. 2014;39(1):67-87. doi:10.5465/amr.2011.0396
  28. Saario S. Managerial reforms and specialised psychiatric care: a study of resistive practices performed by mental health practitioners. Sociol Health Illn. 2012;34(6):896-910. doi:10.1111/j.1467-9566.2011.01439.x
  29. Goss ME. Influence and authority among physicians in an outpatient clinic. Am Sociol Rev. 1961;26(1):39-50. doi:10.2307/2090511
  30. Henderson-Loney J. Tuckman and tears: developing teams during profound organizational change. Supervision. 1996;57(5):3-5.
  31. Wiggins L. Managing the ups and downs of change communication. Strategic Communication Management. 2008;13(1):20.
  32. Airoldi M. Disinvestments in practice: overcoming resistance to change through a sociotechnical approach with local stakeholders. J Health Polit Policy Law. 2013;38(6):1149-1171. doi:10.1215/03616878-2373175
  33. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low‐value health care practices: an Australian study. Med J Aust. 2012;197(10):556-560. doi:10.5694/mja12.11083
Volume 8, Issue 7
July 2019
Pages 403-411
  • Receive Date: 29 August 2018
  • Revise Date: 05 April 2019
  • Accept Date: 06 April 2019
  • First Publish Date: 01 July 2019