How to cost the implementation of major system change: case study using reconfigurations of specialist cancer surgery in part of London, UK [Presentation]
HSRUK 2020
Abstract
HSRUK 2020
- Abstract of a presentation given at HSR UK 2020 illustrating a framework and principles for costing major system change implementation. The case study uses the RESPECT-21 mixed-methods evaluation of specialist surgery services reconfiguration for prostate, bladder, renal and oesophago-gastric cancers, and focuses on a London region [UCL] where services for eight cancer pathways were centralised to fewer high-volume units.
- Presentation available here. [YouTube]
Abstract
Background: Studies have been published on the impact of major system change (MSC) on care quality and outcomes, but few evaluate implementation costs or include them in cost-effectiveness analysis (CEA). This is despite their potential influence on implementation decisions, and potential large costs, associated with for example change planning, purchasing or repurposing assets, and staff time. We present a case study illustrating our framework and principles for costing MSC implementation, which we have developed previously during work on stroke.
Methods: We outlined MSC implementation stages and identified components, using the new MSC costing framework. We present a case study using the RESPECT-21 mixed-methods evaluation of specialist surgery services reconfiguration for prostate, bladder, renal and oesophago-gastric cancers, focusing on a London region where services for eight cancer pathways were centralised to fewer high-volume units. Health economists collaborated with qualitative researchers, clinicians and managers, identifying key reconfiguration stages and expenditures. Data sources (n=100) included meeting minutes, interviews, and business cases. NHS finance and service managers and clinicians were consulted. Using bottom-up costing, items were identified, and unit costs based on salaries, asset costs and consultancy fees assigned. Itemised costs were adjusted and summed, and discounting approaches explored.
Results: Cost components included: (A) options appraisal, bidding process, external review; (B) stakeholder engagement events; (C) planning/monitoring boards/meetings; and (D) making the change: new assets, facilities, posts. Other considerations included: hospital tariff changes; costs to patients; patient population; and lifetime of changes. Using the framework facilitated data identification and collection. Present value of the total implementation cost, adjusted to 2017-18 prices, was estimated at £5.1 million, of which £1.1 million could be attributed to other concurrent reconfigurations. The total was disaggregated into the following categories: replacing robots (£2.8 million), consultancy fees (£1.4 million), staff time costs (£0.8 million) and other costs (£0.1 million).
Implications: The framework and principles can be used by funders, service providers and commissioners planning MSC, and researchers evaluating MSC. We suggest that health economists should be involved early alongside qualitative and health-service colleagues, as retrospective capture risks information loss. These analyses are challenging; many cost factors are difficult to identify, access and measure, and assumptions regarding time horizon are important, as our case study illustrates. Including implementation costs in CEA might make MSC appear less cost-effective, influencing future decisions. Future work incorporates this implementation cost into the full CEAs of the London Cancer reconfiguration.
Methods: We outlined MSC implementation stages and identified components, using the new MSC costing framework. We present a case study using the RESPECT-21 mixed-methods evaluation of specialist surgery services reconfiguration for prostate, bladder, renal and oesophago-gastric cancers, focusing on a London region where services for eight cancer pathways were centralised to fewer high-volume units. Health economists collaborated with qualitative researchers, clinicians and managers, identifying key reconfiguration stages and expenditures. Data sources (n=100) included meeting minutes, interviews, and business cases. NHS finance and service managers and clinicians were consulted. Using bottom-up costing, items were identified, and unit costs based on salaries, asset costs and consultancy fees assigned. Itemised costs were adjusted and summed, and discounting approaches explored.
Results: Cost components included: (A) options appraisal, bidding process, external review; (B) stakeholder engagement events; (C) planning/monitoring boards/meetings; and (D) making the change: new assets, facilities, posts. Other considerations included: hospital tariff changes; costs to patients; patient population; and lifetime of changes. Using the framework facilitated data identification and collection. Present value of the total implementation cost, adjusted to 2017-18 prices, was estimated at £5.1 million, of which £1.1 million could be attributed to other concurrent reconfigurations. The total was disaggregated into the following categories: replacing robots (£2.8 million), consultancy fees (£1.4 million), staff time costs (£0.8 million) and other costs (£0.1 million).
Implications: The framework and principles can be used by funders, service providers and commissioners planning MSC, and researchers evaluating MSC. We suggest that health economists should be involved early alongside qualitative and health-service colleagues, as retrospective capture risks information loss. These analyses are challenging; many cost factors are difficult to identify, access and measure, and assumptions regarding time horizon are important, as our case study illustrates. Including implementation costs in CEA might make MSC appear less cost-effective, influencing future decisions. Future work incorporates this implementation cost into the full CEAs of the London Cancer reconfiguration.
