http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(6): 493–494 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.941212
EDITORIAL
Exploring issues of cost and value in professional and interprofessional education Kieran Walsh1, Scott Reeves2 and Stephen Maloney3 BMJ Learning, London, UK, 2Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK, and 3School of Primary Health Care, Monash University, Clayton, Victoria, Australia
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Introduction Over the past decade or so there has been a growing interest from policymakers, professionals, students and the public on the amount of money that is spent on educating health and social care professions and the ‘‘value’’ this investment may generate for wider society. In this editorial, we discuss the differing element relating to cost and value in the context of professional and interprofessional education. We argue that while there is an increasing pressure to provide evidence in the form of costeffectiveness, cost-benefit and cost-utility analyses for health professions education, collectively, we continue to provide only a limited effort in response. In addressing this gap, we go on to outline some possible routes forward to begin generating and synthesizing evidence for cost and value for interprofessional education.
Considering cost and value in health professions education The education of healthcare professionals is expensive (Walsh, 2010). There is the cost of undergraduate education, postgraduate training and then continuous professional development. There is the cost of educating doctors, nurses, therapists, pharmacists and social workers. These costs quickly become substantial at a national or international level. For example, it was estimated the UK spends £4.9 billion on the educational of its healthcare professionals (The Higher Education Academy, 2014). Many components of this spend have been subject to intense scrutiny over the past decade. For example, the proportion of the budget that is spent on drugs is now strongly influenced by the work of the National Institute of Clinical Excellence (NICE). Using well-developed methodology, NICE decides whether or not to recommend certain new drugs on the UK National Health Service based on explicit data regarding the drugs’ cost effectiveness (Walker, Palmer, & Sculpher, 2007), If a drug is deemed to be too expensive and/or insufficiently effective, then it will not be made available. However, the same is not the case with the annual spend on health professions education. There is little evidence as to what forms of health professions education are cost effective or have favourable cost-benefit or cost-utility ratios. Few trials and Correspondence: Kieran Walsh, BMJ Learning, BMA House, Tavistock Square, London WC1H 9JP, UK. E-mail:
[email protected]
few systematic reviews exist in this field (Walsh, 2013). There is also a lack of transparency as to where exactly the funding goes. Monies for undergraduate medical education, for example, are too often used to fund research, and monies for postgraduate medical education too often used to fund clinical care (Dacre & Walsh, 2013). And there is increasing recognition that the whole issue of cost and value in health professions education is important. From the cost perspective, it is a sizeable amount of money. From the effectiveness perspective, it is most important that we get the education of our healthcare professionals’ right. Both are important to the payer – who might be the tax payer or the individual learner.
Interprofessional education: cost and value What is true of the cost and value of health professions education as a whole is equally true of the cost and value of interprofessional education. It has been noted that there are a few original research articles in the interprofessional literature examining issues of cost and value (e.g. Reeves, 2010; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). Indeed, it has been argued that such articles are often limited in nature, and certainly do not add up to a coherent and strategic approach to this field (Nestel, Williams, & Villanueva, 2010). However, interprofessional education can follow tried and trusted pathways to develop its economics base. The first step in any cost analysis of an interprofessional education intervention is to gather up all of the elements of the intervention, and then assign a cost to each component. Establishing a comprehensive and accurate account of the cost base is vitally important as this is the foundation stone of any subsequent cost analysis. If the cost base is incorrect then the rest of the analysis will inevitably be incorrect. The next step is undertaking the cost and value analysis itself. Here, a number of tools are available. No tool is necessarily better than another – they all have advantages and disadvantages depending on the contexts in which they are deployed (Walsh, Levin, Jaye, & Gazzard, 2013). Cost-effectiveness analyses imply a comparison between different educational interventions to find out which one is the most cost effective. They might be useful if one form of interprofessional education is compared with another. Cost-benefit analyses involve balancing the cost of a healthcare professional education intervention with the monetary benefits that accrue from its implementation. Costutility analyses may work best in cost analyses of different forms
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of assessment – where the various components constituting the utility of an assessment (e.g. validity or reliability) can be balanced against its cost. Expert advice should be taken before using these tools in the context of interprofessional education. It is unlikely that one approach will be more or less suited to questions regarding interprofessional education – it is more likely that the choice will be influenced by the exact question being asked. However, there is one important point to take into account when discussing interprofessional education. For some, interprofessional education has been seen as a means of saving money. At one level, it does seem attractive to deliver interprofessional content to different groups of health and social care professionals together rather than provide the same educational content to different groups separately. However, while such an approach may appear economically appealing, it may not work or be effective in practice. Indeed, interprofessional education when delivered properly might be cheaper and more effective than uniprofessional approaches. Although it might not be. It might actually require more investment to make it function effectively. However, any increased investment may be worthwhile. Cost analysis in healthcare professional education should be ideologically neutral – they should not have a covert political agenda of saving costs or justifying budgets. In fact, they can be student-centred, looking at the cost of participation, and the subsequent accessibility of the education. Given this sizeable gap in our knowledge, in a foreseeable near-future, it should be the norm for teaching and learning of research methods to include measures of cost and value, alongside effectiveness, to ensure the learning experience provides quantitative, qualitative and economic perspectives. A near-future where educational researchers would aim to consult with colleagues who are competent in economic analyses, just as frequently as they would consult with, for example, a statistician.
Concluding comments Although this editorial mentions some of the short-comings of the research literature on cost and value relating to professional and interprofessional education, these short-comings also constitute an opportunity. Almost any original research that is undertaken to fill in the gaps in the evidence base will be innovative. There is also a need for more systematic reviews. In addition, the methodology needs to be developed so that generic cost measurement and cost analysis tools can be tailored to fit with the existing frameworks of effectiveness within interprofessional education. Including a prospective analysis of
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cost and value into educational research will improve the impact of the research findings, by helping to inform the financial risks and benefits of translating evidence into practice. Lastly and most significantly, there is an opportunity for institutions to emerge as centres of excellence in cost and value in interprofessional education. International centres of excellence exist for other fields across health professions education – it is just a matter of time before similar occurs in this field. A new society for cost and value in medical education (SCVME) has been set up for educational researchers, designers and decision makers from all health professions. It points out new evidence and facilitates discussion and networking in this arena. (More on the SCVME can be found at: http://www.med.monash.edu.au/sphpm/scvme/ index.html or followed on Twitter.) If you have ideas for articles for the Journal of Interprofessional Care, then we would be delighted to hear from you.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
References Dacre, J., & Walsh, K. (2013). Funding of medical education: The need for transparency. Clinical Medicine, 13, 573–575. The Higher Education Academy. (2014). Cost and value in medical education: How will we know whether educational interventions are value for money? The Higher Education Academy Event, London, UK. Retrieved from http://www.heacademy.ac.uk/events/detail/2014/ Workshop/HSC/28-04-14-cost-and-value-in-ME Nestel, D., Williams, B., & Villanueva, E. (2010). Cost effectiveness in interprofessional education. In K. Walsh (Ed), Cost effectiveness in medical education. Abingdon: Radcliffe. Reeves, S. (2010). Ideas for the development of the interprofessional field. Journal of Interprofessional Care, 24, 217–219. Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: Effects on professional practice and healthcare outcomes (update). Cochrane Database Systematic Review, 3, CD002213. doi: 10.1002/14651858.CD002213.pub3. Walker, S., Palmer, S., & Sculpher, M. (2007). The role of NICE technology appraisal in NHS rationing. British Medical Bulletin, 81–82, 51–64. Walsh, K. (Ed). (2010). Cost effectiveness in medical education. Abingdon: Radcliffe. Walsh, K. (2013). Cost and value in medical education. In K. Walsh (Ed), The Oxford textbook of medical education. Oxford: Oxford University Press. Walsh, K., Levin, H., Jaye, P., & Gazzard, J. (2013). Cost analyses approaches in medical education: There are no simple solutions. Medical Education, 47, 962–968.
