Star is a new approach to priority setting in healthcare, which combines value for money analysis with stakeholder engagement. It was developed by Professor Gwyn Bevan’s team at the London School of Economics and Political Science (LSE) and funded by the Health Foundation. We talk to Professor Bevan about how Star can help commissioners to engage with local stakeholders and make more transparent decisions about healthcare resources.
Tell us about Star
Star can be used by people planning health services when they need to make informed decisions about how to allocate resources, enabling them to maximise the benefits of health services, while also making efficiencies.
Star stands for 'socio-technical allocation of resources'. This is because we use a social process that involves key stakeholders, alongside the technical use of visual models to help understand and present the data. This combined approach makes it easier for stakeholders to understand the options and make confident decisions about resource allocation.
How was it developed?
Star emerged from a programme of research and development into value for money in healthcare carried out by my team at LSE. The Health Foundation funded our work over eight years, moving from methodological research into development of a practical tool.
We developed the Star tool through two pilots, led by my colleague Mara Airoldi. The first was with the Isle of Wight PCT, where a member of our research team, Dr Jenifer Smith, was the Medical Director and Director of Public Health. This was in 2008 and health services were in a very different place to now. The Trust had about £1m of growth money and needed to choose between 21 different options for how to spend it. The PCT used Star to decide on its strategy and won an award from the Strategic Health Authority for its approach.
More recently we piloted the Star process in NHS Sheffield where it was used to improve benefits and reduce costs in their eating disorder services. Working in a different climate, one of austerity, that project was about finding efficiencies. Star enabled the PCT to redesign services to do just that.
How does the Star analysis work?
Star requires three types of data for each intervention you are examining: how many people you can treat, what it costs, and its value. The data on numbers and costs are usually available, but there is often less information on benefits. Star helps to provide this, enabling key stakeholders to generate the missing data by estimating the relative value of interventions in a structured way.
The stakeholder group must include patients and carers as well as clinicians, providers, commissioners, epidemiologists and representatives of agencies involved in the care pathway. We bring everyone together in workshops using ‘decision conferencing’, a process developed by Professor Larry Phillips at LSE.
Star then collates all the data about numbers, cost and value into two visual models: 'rectangles of population health gain' and 'value for money triangles'. Here's an example of some value for money triangles:
When you plot them all out in a picture, you can see at a glance which interventions are good and which are poor value. It’s a simple and accessible way of visually communicating very complex information. Everyone understands it. And the stakeholders who’ve been involved in the pilots say the process is satisfying and gives them the confidence to make decisions.
How can Star help to engage with patients and carers?
Organisations are often wary of involving patients and carers in decisions about reallocating resources, but we believe it’s vital to do so to be able to estimate value. In reality the risks are small and the potential benefits are huge.
And people can surprise you. The Sheffield pilot of Star showed that 80% of spend on eating disorders was going on intensive residential care, which was poor value for money. You might think, like the research team, that the patients and carers involved wouldn’t want to cut back on this service. But having seen and understood the analysis, they actually wanted the resources to go towards other interventions instead as they could see these offered better value for money and would reduce the need for residential care.
In these hard times healthcare commissioners have to make difficult choices and unpopular decisions. Using Star ensures that stakeholders have contributed to decisions and fully understand the choices that need to be made. Furthermore, this process gives credibility to strategies when going out to public consultation.
What advice would you give to organisations thinking of using the Star tool?
Take a look at the toolkit. If you want to try Star, it’s a good idea to trial the approach with a small manageable project first, so that people understand the tool and why it’s worth committing time to the process.
The models are easy to use, but it’s really important to have a skilled and impartial facilitator to lead the decision conferencing work. We are looking into how we can develop training to support this.
How else is Star being used?
We’re working to get CCGs involved in Star and have run further pilots in three areas to test the user-friendliness of the tool. We’ve also been developing train the trainer sessions.
We’ve enjoyed collaborating with IMPRESS (Improving and Integrating Respiratory Services in the NHS). Our work with them on Chronic Obstructive Pulmonary Disease used Star to work out which interventions have the greatest benefit and was praised by a leader in the BMJ.
We’re also doing exciting work with the Global Fund. They are funding further work using Star to help developing countries allocate their limited resources to fight three killer diseases: AIDS/HIV, tuberculosis and malaria. We’ve already piloted Star in Bangladesh and the Sudan.
It just shows that the Star approach has huge potential to be adapted for use at all levels, locally, nationally and internationally.
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