The Prato Statement on cost and value in professional and interprofessional education

Introduction

The issue of cost and value in our health workforce training methods is both international and interprofessional. Cost and value research sits at the interface of educational design and workforce planning. Aside from its influence on quality health service provision and health outcomes, cost and value influences student debt, professional attrition, skills migration, and health workforce shortages (Foo, Storr, & Maloney, 2016; Rivers et al., 2015; Sá, 2014).

The education of our health workforce is expensive, with total global expenditure for health professional education estimated at US$100 billion per year (Frenk et al., 2010; Walsh, 2010). Training cost per student in both the public and private sector continues to rise at a rate above inflation (Desrochers & Wellman, 2011). Despite the large economic investments made in health professions education, by both students and society as a whole, we do not know enough about how this money is spent, the return on investment to society, and whether optimal use of limited resources is being achieved.

The efficiency and effectiveness of our health workforce training methods are essential in a climate of health workforce shortages, an aging population, and where issues of health workforce migration continue to undermine the universal provision of quality healthcare in less developed nations (Ahmed, Hossain, Rajachowdhury, & Bhuiya, 2011; Global Health Workforce Alliance, 2008, 2013; World Health Organization, 2010).

Financing is at the heart of enabling feasible upscaling of health professions education (World Health Organization, 2013). However, without evaluating the costs and effects of teaching methods, how are we to determine whether or not widespread adoption of particular teaching methods would be financially sustainable, or deliver the desired workforce productivity? For example, the World Health Organization (2013) scalability report recommends consideration of interprofessional education and e-learning. However, in some cases, these approaches have been found to be more costly than traditional methods (Cook, 2014; Haines, Kent, & Keating, 2014). Despite higher implementation costs, if there is a proportionally larger increase in the desired outcomes (i.e. simulation for increasing competence in arthroscopic surgery), then the method will be more cost-effective and should be adopted from an economic point of view. To date, few studies of teaching in professional or interprofessional contexts have explored how to optimise value, considering both cost and effect (Walsh, Reeves, & Maloney, 2014; Zendejas, Wang, Brydges, Hamstra, & Cook, 2013).

The World Health Organization (2016) report from the High-Level Commission on Health Employment and Economic Growth includes specific recommendations on the need for robust research and analysis of health labour markets, which includes better understanding of the costs in education and lifelong learning. There is a recognised need for harmonised metrics and methodologies to strengthen evidence, accountability, and action.

The Prato Statement proposes that the goal of economic analyses in professional and interprofssional education is to create an evidence base towards education that delivers maximum value for a given spend—and that drives education that is sustainable, accessible, and able to meet future healthcare requirements.

Towards this goal, this editorial presents the Prato Statement, which provides several recommendations that are aimed at guiding the agenda for cost and value research in professional and interprofessional education, through addressing elements of educational research knowledge, policy, and culture. The founding members of the Society for Cost and Value in Health Professions Education (SCVHPE, 2016) conceived this statement at the inaugural Symposium, held in Prato, Italy, in October 2015.

Recommendations

Knowledge

Develop resources to promote basic economic literacy in creators and users of health professions education research

The first and foremost influence on decision making in cost and value in professional and interprofessional education should be evidence-based knowledge (Walsh, 2014c). However, the quantity and the quality of the research, along with the ability to interpret and adopt research findings, are reliant on the economic literacy of our educational research community.

Many researchers have recognised the need for including measurements of cost and value alongside their educational research; however, this has often been done haphazardly and at times incorrectly (Walsh, 2014a, 2014b; Walsh, Levin, Jaye, & Gazzard, 2013). This is perhaps not surprising given the relatively new attention given to this field and the subsequent lack of guiding documents and resources available for it. Furthermore, attributes of economic evaluations and cost and value analyses have not historically featured in our typical curriculum for health professional education or research training.

Although method papers for economic evaluation in health professions education are becoming more common, such as Tolsgaard et al. (2015) and Haines, Isles, Jones, and Jull (2011), there is currently no comprehensive guide which would allow a novice to comprehend or conduct research in this field. The development of a best practice guide, such as the guide by Sharma, Gordon, Dharamsi, and Gibbs (2015) on conducting systematic reviews, may provide health professions educators and educational researchers the support to incorporate cost and value components into their evaluations.

Establish minimum standards for published literature

The field of cost and value in professional and interprofessional education needs to move towards establishing and disseminating minimum acceptable standards for the design and reporting of cost and value research.

Many research methodologies have both reporting guidelines and quality appraisal tools. For example, systematic reviews have the PRISMA checklist for reporting and AMSTAR checklist for quality appraisal, while randomised controlled trials have the CONSORT statement and PEDro scale for the same reasons, respectively (Begg et al., 1996; Maher, Sherrington, Herbert, Moseley, & Elkins, 2003; Moher, Liberati, Tetzlaff, Altman, & The Prisma Group, 2009; Shea et al., 2007). There are also several resources that exist to guide evaluations in health economics, such as the Drummond’s checklist and the CHEERS statement (Drummond, O’Brien, Stoddart, & Torrance, 1997; Husereau et al., 2013). However, these tools have several limitations when used in educational research, due to particular items and nomenclature incongruent with educational processes.

Policy

Develop the expectation for measures of cost and value alongside educational studies

Consideration of cost and value has long been an accepted component of decision making in health policy and planning, explored through the field of health economics. In order to make the best use of finite resources, it is commonplace to see economic evaluations alongside clinical trials (Hutubessy, Chisholm, & Edejer, 2003). Similarly, resources in education are also limited, with the tension in funding only expected to increase in the future (The Economist Intelligence Unit, 2016). Why then, is it not commonplace to evaluate the cost and value of our educational practices?

Policy change is required to promote and facilitate cost and value research, changing the way we evaluate through a top-down approach. Prospective cost-analyses alongside educational trials would require minimal further financial or resource outlay and would facilitate the translation to practice of the study findings. Effectiveness of an educational intervention should be measured not only by its potential to increase learner competency, but also value the monetary and non-monetary outcomes and resources, such as the quality of the learning experience, and change in health outcomes.

Consider multiple perspectives of cost and value in decision making

Effective policy requires consideration of multiple viewpoints. For cost and value analyses to provide effective guidance of policy, it should also take into account multiple viewpoints to represent the numerous stakeholders in health professions education. This is particularly relevant to interprofessional education, as the allocation of costs and effects is likely to be spread across a larger number of stakeholders, and thus the true cost and value may not be readily apparent (Nestel, Williams, & Villanueva, 2010).

The division of cost between stakeholders is illustrated in an investigation by Haines et al. (2014) of an interprofessional clinic as an alternative to traditional profession-specific clinics within a hospital-based setting. Their study revealed an increase in costs from the perspective of the university, but a saving for both the state and national governments, resulting in an overall increased cost to society (combining the perspective of all stakeholders) compared to the traditional hospital-based placements. Decision making may also be informed by the student cost and value perspective, as studies have found correlations between university fees and the level of university applications as well as future career choices (Sá, 2014). Measuring student value in education policy or practice promotes a student-centred approach and is an important link between the efficacy of the education and the learning experience (Maloney et al., 2012).

Culture

Encourage academics to use economic reasoning to advocate for change and demonstrate their educational worth

The relationship between health professional educators and administrators can at times be adversarial, due to the perceived conflict of interests between providing the best education possible and ensuring financial sustainability. This is particularly true with the increase in private education institutions, which have the duel agendas of education and profit (Walsh, 2015). Many educator experiences of economic evaluations tend to be in the form of staffing reductions, rationalisation of teaching offerings, and feasibility studies for incoming programs, which focus on the ‘business case’. It is therefore unsurprising that many academics are disillusioned about the utility of economic analyses.

However, the development of a cost-effective education system is not possible without the engagement of educators themselves. Academics who are informed on the effectiveness, learning experience, and cost and value of their teaching approaches and policies are best placed to lead change in this sector. Developing a culture where educators take an interest in measures of cost and value allows them to make stronger arguments for desired changes and empowers them to have greater involvement in budgetary decisions (Walsh, 2016).

Research income is a common measure used to demonstrate the standing of a researcher within their institution and often leveraged for both promotion and increasing resources (Bazeley, 2010). In contrast, health professional educators rarely utilise similar arguments and are often unaware of the proportion of the institutions’ student-related income for which they effectively manage. Understanding of cost and value allows academics to further demonstrate their worth to institutions. Furthermore, institutional recognition of educators who effectively leverage the concepts of cost and value may prompt more educators to do likewise and thus spread change throughout the organisation.

Concluding comments

The Prato Statement proposes that the goal of economic analyses in professional and interprofessional education is to create an evidence base towards education that delivers maximum value for a given spend. There appears to be a need to increase the basic economic literacy of our educational researchers and decision-makers, which may be facilitated through development of best practice guidelines and minimum standards for the reporting and quality of disseminated literature. Encouragement should be provided for prospective measures of cost and value alongside educational studies, in order to facilitate the translation to practice of the study findings. Educators need to be empowered to utilise economic arguments for leading change and demonstrating their worth. An improved evidence base in this field can assist research-informed policy and position us for providing education for the health and social care professions that is sustainable, accessible, and able to meet future healthcare requirements.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgements

We would like to acknowledge the Monash University Office of Learning and Teaching for their vision in seeing the importance of this field for improving teaching and learning practice and policy.

Funding

The authors are all part of the Society for Cost and Value in Health Professions Education, a society dedicated to the community of educators, researchers, and administrators interested in the cost and value of medical education and sustainable and effective workforce development. The society does not receive any financial contributions from any members or any other parties. This society was initiated through the generous funding from the Higher Education Research and Development Society of Australasia in 2012. Funding for this work was received from the Monash University Office of Learning and Teaching.

Additional information

Funding

The authors are all part of the Society for Cost and Value in Health Professions Education, a society dedicated to the community of educators, researchers, and administrators interested in the cost and value of medical education and sustainable and effective workforce development. The society does not receive any financial contributions from any members or any other parties. This society was initiated through the generous funding from the Higher Education Research and Development Society of Australasia in 2012. Funding for this work was received from the Monash University Office of Learning and Teaching.