{"id":397,"date":"2019-06-07T10:03:16","date_gmt":"2019-06-07T10:03:16","guid":{"rendered":"http:\/\/blogs.kcl.ac.uk\/clahrc-south-london\/?p=397"},"modified":"2019-06-07T14:11:32","modified_gmt":"2019-06-07T14:11:32","slug":"change-for-with-or-against-the-public-the-ethics-of-disinvestment","status":"publish","type":"post","link":"https:\/\/blogs.kcl.ac.uk\/clahrc-south-london\/2019\/06\/07\/change-for-with-or-against-the-public-the-ethics-of-disinvestment\/","title":{"rendered":"Change for, with or against the public \u2013 the ethics of disinvestment"},"content":{"rendered":"

Peter Littlejohns, deputy director of the CLAHRC and public health theme lead, reflects on the ethics of disinvestment, and whether they should be seen as separate from the ethics of investment.\u00a0\u00a0<\/strong><\/p>\n

\u201cEthics\u201d workshops appear to be like buses \u2013 they never seem to come and then two arrive at once. My blog last month described a workshop addressing the ethics of improvement science<\/a>.<\/p>\n

This month Gry Wester, Catherine Max and Vicki Charlton of the King\u2019s College London \/ UCL Social Values group organised a workshop on the ethics of disinvestment<\/a>. I have blogged about this tricky issue before<\/a>. While social scientists have always said that \u201ctaking something away from someone is different to having not given them it in the first place\u201d, do ethicists concur?<\/p>\n

While most people agree that disinvesting is difficult, the day started with Jill Manthorpe, Professor of Social Work at King’s College London, describing how day centres bucked the trend and were de-commissioned (inappropriately so) with remarkable haste. Discussion centred on whether social care was different from health or merely that social care was in an even bigger financial crisis than health (councils have lost\u00a0 50% of their budget since the crash and some are on the verge of bankruptcy<\/a>. There is also an issue of how to measure costs and benefits and Jill raised the challenge of measuring social value.<\/p>\n

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The next two speakers explored international approaches to disinvestment (Janet Bouttell \u2013 University of Glasgow) and how English CCGs have approached the challenge (lestyn Williams \u2013 University of Birmingham). Both suggested that the efforts have been greater than the results. The final speaker of the morning Scott Greer (from Michigan University, USA, but currently visiting LSE) highlighted his research on how systems approach disinvestment. With the catchy title of “Change for, with or against the public: three logics for service redesign in the UK<\/a>“) he described how these challenges are faced in England, Wales and Scotland. He concluded there were three logic models of change, and that we should not be surprised how difficult it is to bring about major change, but we should identify some pitfalls to avoid.<\/p>\n

After lunch the next set of speakers (Mark Sheehan (University of Oxford) and James Wilson (UCL) addressed the specific question of whether disinvestment raises unique ethical issues or whether they are similar to those of bringing new interventions into the health service. They debated the concept of \u201cethical equivalence\u201d and its application to \u201cgrandfather clauses\u201d in NICE guidance.\u00a0 Judging by the level of delegate discussion, this debate, particularly with James introducing the concept of \u201creasonable expectations\u201d is to be continued \u2013 I feel another thought paper coming on. The day concluded with a \u201creal\u201d commissioner Jim McManus, Director of Public Health from Hertfordshire County Council, describing the dilemma of stopping services on a day-to-day basis.<\/p>\n

So what did I get from the day? Well I think that my starting position that disinvestment should not be treated differently from investment, and that they are paired aspects of a single prioritisation process still stands. Over the years I have been involved in three major initiatives to mainstream disinvestment activities. I was a part of group informing the initial Australian attempt – the Astute Project:<\/p>\n