“This is cost saving”A note on ‘invest to save’ proposals


The world is full of proposals that start with ‘if only we made this investment, then we could save xxxx’. 

The number of new ideas that are TRULY cost saving (esp where there is unmet need) are very small indeed.

Problem – The savings rarely come to fruition. 

For many reasons

Reality of assumptions – often no basis in evidence. We’ve all been told that investing in xxxxxxx will result in a 75% reduction in admissions haven’t we…..

Ability to count the savings in cold hard cash, esp in prevention arena

differential timing of investment and savings complicates further. 

Unmet need.

Unless the supply is removed, someone still has a problem as the fixed costs of the supply will need to be met.

The tricky issue of saving in the population treated versus the broader population

Thus “invest to save” is a tricky area

5 suggestions for making decisions on ‘Invest to save’ proposals

1. clear and good q evidence re clinical and cost effectiveness – it could work. 

a) What is enough evidence?

Audit that was published in the Eastern Bulgarian Journal of Ingrowing Toenail Disease (I’m sure there is such a journal)

Full mashing RCT

case report highlighting it worked somewhere else therefore we should adopt it here…..care re Decisions based on uncontrolled before and after studies…….esp in uncontrolled unpiloted way……

b) Is it cost effective, It is worth it. nb if someone tells you it’s cost effective and the cost / QALY is less than £20,000- thus NICE would approve it….this does NOT, I REPEAT NOT, mean it will save cash. 

2. Clear business case demonstrating is HAS worked somewhere else

This is tricky for genuinely innovative stuff that’s never been tried anywhere else

Ask yourself is the innovation and the possible reward worth the level of financial risk you want to bear

3. Clear proposal – is the proposal for funding clear.

I often apply the PICO acronym

What is the Population that will receive the intervention. Is it clearly set out. If not, push back

What exactly is the intervention – is it clearly described. In a way that you could then specify an evaluation (see below)

What is the Comparator – incremental cost and incremental effectiveness is all. Is the suggested comparator, whether standard care or otherwise the right comparator.

What is it being compared against. What is standard care. A clear articulation of why this intervention is better

What it the outcome – can it me measured with the the data that is available

what is going to be monitored. When. By whom. How soon will we know it is working.

4. Is there the right management capacity and the right incentives and levers to actually make it work

Even amazing ideas don’t implement themselves

The originator of the idea will doubtless be crazily innovative and won’t want to be troubled by the nasty business of implementation.

Make sure someone IS in place to ensure it is implemented as planned.

5. A clear plan for realizing any savings in hard cash

The hard bit.

Finally – ask what the evaluation plan is.

This is not the same as “performance monitoring”

Who will evaluate what – process and outcome evaluation questions are important

Did it work (once you’ve defined what work means) and why, what were the unanticipated issues.


You should use these questions judiciously

And within an ethical framework

But you should use them.




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