Cost and Value in Healthcare Professional Education – Why the Slow Pace of Change?

To the Editor. The first major review of cost and value in healthcare professional education was in 2002.1 The first book on the subject was published in 2010, and here I must confess a personal interest – I was the editor.2 Since then several articles have been published on this subject.3,4 There are numerous factors that should continue to drive forward the agenda of cost and value in healthcare education5; however, the pace of change has been slow. Most educational interventions are still not costed properly or not costed at all, ie, educators have not undertaken a comprehensive analysis of the cost involved in the implementation of these interventions.6 Most educational interventions are not evaluated for their cost effectiveness, benefit, or utility. There has been progress but much work remains to be done. It is worth asking why the pace of change has been slow. The answer is that there are barriers to change. There are some generic barriers that will slow down any change; there are some barriers that are specific to cost and value. Foremost among the generic barriers is the lack of knowledge among educators about cost and value. This is evident in the few papers that do mention cost – commonly cost effectiveness is confused with cost utility or cost benefit. Along with lack of knowledge comes a fear of change. There probably has been underinvestment in healthcare education for many years, and that underinvestment remains. The new interest in cost and value may have led some to believe that funding may be further cut. There may be concerns about the underlying strategy behind the interest in cost and value. Some may see it as a way of saving costs, others as a means of justifying increased spending – but until consensus emerges about why we are looking at this subject, there will be concerns about the underlying agenda. Some stakeholders may see the issue as a means to improve governance and accountability; others may see it as a means of demonstrating efficiency. As with any new initiative, there have been some successes, but these have not always been communicated. It can be difficult to publish papers on cost and value as even specialist journal editors lack knowledge of the subject. Some don’t think that concepts of cost and value can be applied to education as it is too complex for its costs or effectiveness or benefits to be captured in quantitative terms. A number of research projects need to be completed and published – only then will the issue of cost and value become mainstream. Motivation is a potential obstacle. Currently, there is little motivation for educators to deliver more cost-effective education. There may be perverse incentives whereby savings in one year result in lower budgets the next year. Often there are practical barriers. There may be a lack of expertise about how best to analyse cost and utility and how to institute changes. New resources or personnel may be needed to bring about change - all of this will need to be managed. There are certain barriers that are particular to the issue of cost and value. These include concerns that the methods used in cost analyses are not fit for purpose.7 Progress has been made in terms of defining quality standards for cost analyses generally, but to date no standards have emerged defining high-quality cost analyses in healthcare professional education. There are also concerns about the applicability of academic cost analyses to the real world of education. Cost analyses in healthcare professional education might be too narrow to be relevant to the real world. Perhaps the greatest barrier is that readers of cost analyses do not trust the motivation of those conducting them. Readers may wonder whether private providers of education who demonstrate perhaps the favorable cost utility of their techniques may have deliberately or inadvertently missed costs or exaggerated utility. Other readers may wonder whether investigators who discover cost inefficiencies may be planning cuts. Lastly, there are concerns about publication bias – whereby researchers only publish results that are consistent with their prejudices.8 Affecting all barriers is the fact that such barriers are rarely sought out, defined, declared, and addressed. The challenge to those with an interest in cost and value in healthcare professional education is to take these steps to seek them out, define, and overcome them.