Star – a tool for commissioners

Socio-technical allocation of resources

The current health care landscape demands that those who plan or commission services – at local, regional, or national level – provide high quality health and social services that offer good value for money. There is also a requirement to involve patients and the public in decisions about service planning.

Together with the London School of Economics (LSE), the Health Foundation has developed the Star approach to help those who plan or commission services to work with their stakeholders to allocate resources to benefit patients in their community. The approach combines value for money analysis with stakeholder engagement. Teams use an Excel-based tool alongside a facilitated stakeholder workshop.

While Star is primarily designed for health care commissioners, it is suitable for anyone charged with making decisions about resource allocation as they plan services.

Key to the Star approach is the involvement of all stakeholders in a workshop process of structured decision analysis, so informed decisions about resources can be made. For this to be successful, the workshops are led by a skilled and experienced Star facilitator.

Workshops

The Star facilitator starts working with the organisation before the workshop(s). Preparation begins with an initial meeting between the Star facilitator and the team who are responsible for resource allocation decisions to discuss the goal of ‘their’ Star approach. The group needs to agree:

• which area(s) of resource allocation and which interventions they will focus on
• which stakeholders therefore need to be involved (including patient and community representation)
• what data they will need to inform the discussion.

The participants in the workshop, guided by the facilitator, discuss each intervention under consideration to gain a shared understanding of the costs and benefits.

The role of the Excel-based Star tool in the Star approach

The Excel-based Start tool is used to generate graphical displays of the data as comparative 'value triangles', enabling users to compare the relative value for money of health care interventions. These graphics show the ratio of costs to benefit, taking account of individual patient benefit and population health gain, and enable all stakeholders to take part in structured discussions about resource allocation.

The facilitator works with the group to discuss the implications for resource allocation between the interventions and to reach consensus on the next steps after the workshop to act on the conclusions drawn.

The Star tool will not produce a definitive ‘answer’ from the data. It is the technical element of a broader facilitated dialogue – as the diagram below illustrates. It serves as an enabler, turning data into a meaningful output. The tool itself is of little value without the stakeholder discussions part of the Star approach.

This section gives an overview of the functions of the Star tool, giving further information on the Star approach and the role of the Star tool, and introducing you to the most important functionalities of the Star tool: the Context tab, the Priority Area tab, the Outputs tab, and the Lab tab.

We recommend that you download the tool and try it out with some simple data to see how it works before trying to use it on a larger scale.

Filing in the data: the Context tab

The context tab is the first part of the Star tool and allows you to provide the context in which the tool is being used. For example the data you have, the areas of care you are looking at, the stakeholders to involve and whether you are focusing on health inequalities.

The Star approach involves a wide range of stakeholders, who all contribute their own expertise and opinions. While this is one of the great strengths of the Star approach, it can potentially result in heated discussions between participants. To manage this and keep the workshop running smoothly, it is crucial to work with an experienced facilitator.

The guidance for Star approach facilitators describes the requirements for a Star approach facilitator, as well as several challenging scenarios observed during the Star pilots with suggestions on how to manage these.

The Star facilitator guidance does not replace facilitation experience or familiarity with the tool. We recommend facilitators attend a Star approach training session prior to undertaking the workshops.

The methodology at the heart of Star is an example of multi-criteria decision analysis (MCDA). MCDA is a procedure for people faced with a set of options to systematically rank their preferences using a range of different criteria.

Factors

For example, if someone is part of a group choosing between a number of different health care investment options, there may be concerns about:

• cost
• quality of outcome/change in patients’ life
• number of people in the population affected.

But these factors do not all matter equally to all stakeholders. MCDA allows users to judge each option against the criteria, taking all of the stakeholders’ views into account and attaching greater weight to the criteria upon which they place most importance.

The focus of Star

Star focuses on:

• population health gain (the ratio of individual health gain per person to the total number of people benefiting)
• value for money (the ratio of population health gain to costs of a health care intervention)
• how the interventions compare in terms of value for money.

As an additional step, Star can also focus on the potential of specific interventions to reduce health inequalities.

The Star approach does not claim to solve health care resource allocation problems. However it provides a means of systematically working through these criteria to facilitate transparency in decision making.

While high quality data is helpful to get the best out of using Star, the beauty of the approach is that it enables the stakeholders to fill the data gaps by using their combined experience and perspectives to make a ‘good enough’ approximation. This is the basis for the ‘requisite model’ that the LSE researchers have extensively tested to show that such modelling is effective.

Available data

Before a stakeholder workshop, the sources of available data need to be identified and data on the following collated for each intervention to be discussed:

• the numbers of people with the relevant condition in the local population
• the number who could benefit from the intervention
• the cost of providing the intervention for these people.

Data analyst

You will also need someone who is familiar with the local population level health data and experienced in its analysis to lead on this for the local Star approach. They will need to be trained in using the Star tool and to attend each workshop to ensure that data is being used consistently, working closely with the facilitator in order to discuss data gaps and weakness of existing data.

Using data to inform decisions

The Star approach enables better use of the available data to inform decisions and shows where data is lacking.

Participants in pilots report that the real value of Star is in the conversations that occur in stakeholder workshops, allowing participants to trace the use of numerical data and challenge the various assumptions that may influence decisions.

The Star approach has great potential to help make better health care resource allocation decisions.

To get the most out of Star, planning is necessary before using the approach including:

• collate as much of the necessary data as possible – further information can be found in the Star data collection and data gathering sections.
• be sure that relevant people who are organising the local use of the Star approach, understand the Star approach fully and that all steps of the Star approach will be included.
• have a sound understanding of the Star tool – the Star demonstration section will give you an introduction to the tool.
• work with an experienced facilitator to guide you through the Star approach. Facilitators should read the section on facilitating a Star workshop prior to running the workshops.