STAR

STAR helps a health service decide openly what to fund. It brings commissioners, providers and patients together in a workshop, with the best available data on what each treatment costs and does.

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In 2019/20, Mid-Nottinghamshire spent £4.5 million treating 17,225 people for back pain. A group of local clinicians, patients and managers wanted to know whether the money was doing as much good as it could.

To compare treatments, they asked what it costs to give one person an extra year of healthy life. Through physiotherapy, £124 to £171, depending on the provider. Through epidural injections, between £76,327 and £220,612.

The NHS measures benefit in quality-adjusted life years: a year in full health counts as one, a year in poor health counts as less. This page says "healthy year" throughout.

STAR draws the whole budget as one chart. Money runs left to right; the height shows the healthy years bought so far. Treatments are ordered best value first. Nearly all of them come from physiotherapy and rehabilitation.

Tap any part of the chart, or any row of the table, to pick a treatment out.

After the first £900,000, the remaining £3.6 million bought about 3% more health; the final £2.2 million bought no measured benefit at all. The largest items, itemised in the table, are £967,000 of trigger-point injections, £458,000 of MRI scans outside guidelines and £254,000 of spinal fusion.

After the workshop, the plan changed. Cut the scans and injections that were not helping. Spend the money on group classes in poorer areas, digital support at £2 a head, and case management for the most complex back pain. The same £4.5 million could buy 7,661 healthy years instead of 4,571, and treat 10,000 more people.

The after state is the group’s published estimate. No new money is involved.

Click Next to see the impact of STAR in Mid-Nottinghamshire.

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The same figures as the chart, treatment by treatment, ordered best buy first.
Treatment	Spent	Healthy years	Cost of one healthy year
One-to-one physiotherapy	£400,560	3,112	£124–£171
Biopsychosocial rehabilitation	£427,793	1,164	£368
Group classes; assessment service	£98,840	157	£398–£2,666
Spine MRI, within guidelines	£236,173	85	£2,779
Nerve blocks; radio-frequency ablation	£167,799	26	£4,760–£12,966
Back surgery: decompression, disc replacement	£564,801	25	£18,875–£22,659
Epidural injections	£443,737	2.5	£76,327–£220,612
Trigger-point injections	£966,926	0	no measured benefit
Spine MRI, outside guidelines	£458,453	0	no measured benefit
Spinal fusion	£253,809	0	no measured benefit
Spine X-rays	£226,490	0	no measured benefit
Other back surgery	£219,421	0	no measured benefit
Other injections and small items	£100,005	0	no measured benefit

All figures from Ferreira, Wilson, Ison, Oates, Kirkman and Bevan, Variations and value improvement in back pain care in one area of England, Research in Health Services and Regions (2024), tables 3–4 and figures 6–7, open access; the after state is the group’s published estimate. Small items under £20,000 are grouped as “other injections and small items”.

Additional Case Studies

Isle of Wight

STAR was first used on the Isle of Wight, where the primary care trust had about £1m of growth money and 21 options for spending it. The work won an award from the strategic health authority. One of its decisions, to invest in inhaler technique, halved emergency admissions for asthma. The Health Foundation’s report on the work is Improvement in practice: commissioning with the community (2010, PDF).

Sheffield

NHS Sheffield redesigned its services for eating disorders, expanding earlier intervention so that fewer people needed intensive care later. Executives reported better patient experience and costs down 15%, which left more money for other services. The case is written up in the Health Foundation’s report Looking for value in hard times (2012, PDF), in the NHS Right Care Casebook (Airoldi, 2014) and in the LSE impact case study.

Chronic obstructive pulmonary disease

IMPRESS, a joint initiative of the two leading respiratory clinical societies in Britain, used STAR to set out the relative value of the treatments and to write a guide for commissioners (LSE impact case study).

Mid-Nottinghamshire

In Mid-Nottinghamshire, clinicians, patients and managers went through the £4.5m spent on back pain in 2019/20 — the case in the chart above. They found the same money could buy 7,661 healthy years rather than 4,571, and treat 10,000 more people (Ferreira, Wilson, Ison, Oates, Kirkman and Bevan, 2024).

Guidance on using STAR

A brief introduction to the STAR method (video, Health Economics Unit), and a webinar on achieving value in hard times (Health Foundation).

Two Health Foundation reports describe STAR in use: Improvement in practice: commissioning with the community, on the Isle of Wight (2010, PDF), and Looking for value in hard times, on Sheffield (2012, PDF).