Disinvestment in the age of cost-cutting sound and fury. Tools for the Spanish National Health System.

This paper proposes the framing of disinvestment strategies as the "value for money" approach suitable for the current situation of acute budget restrictions. Building on the experiences from other countries, it first reviews the instruments already available for implementing this approach within the Spanish National Health Service (SNS) named (A) The mandate to do it: regulatory framework.(B) The capacity to identify “low value” interventions and produce guidance on best practice.(C) The capacity to monitor compliance to and effects of “enforced” guidance.These three elements have been in place in the SNS for some years now. However their effective alignment in supporting a disinvestment strategy has met with several hurdles. Components of organisational incentives as well as the "technological fascination" affecting professionals' and public perceptions have played a role in Spain as elsewhere. In addition, some idiosyncratic political factors lead to weak mechanisms for the channelling of available evidence into decision-making and the existing SNS technical bodies capped to issue only non-binding recommendations. Sadly, the "cuts across the board" strategy adopted in facing the financial crisis might have finally triggered the required political clime to overcome these obstacles to disinvestment. In the current context, the SNS stakeholders (professionals and the public) may regard the disinvestment proposal of informed local decisions about how best to spend the shrinking amount of resources, getting rid of low value care, as a shielding rationale, rather than a thread.