Title: De-implementation in health and care services: what works, for whom, why, and in which contexts? A Realist Synthesis.
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Where health and care processes are considered to be inefficient or ineffective, managers and organisations equally require guidance about the process of “de-implementation”, an important strategy that is necessary to address current policy of reducing harm, and improving the quality and cost effectiveness across health and care services. Non-evidenced based decisions andpractices that are known to have poor outcomes, cause harm, and are of low value, continue to be in use, but guidance on how to halt them is missing. In the current economic climate, where service practices that don’t need to be provided are in use, this impacts on the quality of care that patients receive, and contributes to the waste of resources. This evidence synthesis will fill a gap in the evidence base by focusing on the use and impact of different processes for de-implementation. Aim: To produce useful programme theory and practical guidance for policy makers, managers and clinicians to help them with de-implementation processes and procedures. Objectives: 1. Generate a concept analysis of de-implementation. 2. Identify and map the range of different de-implementation approaches and/or strategies currently being utilised across health and care, paying attention to ways in which they are assumed to work. 3. Produce a typology of de-implementation types, processes and contexts. 4. Examine and understand the range of anticipated and unanticipated impacts of these approaches and/or strategies across different settings and stakeholders, paying attention to contextual conditions which influence these impacts 5. Generate an evidence-based, realist programme theory that explains the successful processes and impacts of de-implementation 6. Explore, through stakeholder engagement in the review methods, decision-making processes associated with de-implementation 7. Produce recommendations about ways in which different approaches and/or strategies can help managers and service leaders plan and prioritise de-implementation in a systematic and efficient manner 8. Stimulate a wider debate about avoiding and stopping services that are considered wasteful, of low value and non-efficient, for future provision. A realist approach takes into account the recognised complexities in health and care systems, and will be used for this evidence synthesis. The aim will be to develop, test and refine a programme theory about de-implementation. The output generated will be in the form of a programme theory, populated with evidence that describes ‘what works’ about de-implementation strategies and approaches, and the contextual factors that influence their impact on outcomes. We will interview and work with NHS managers to translate this programme theory into actionable recommendations, using practical examples from the evidence. The evidence synthesis will be conducted in 4 phases over 18 months: Phase 1: Concept, and initial programme theory development in consultation with stakeholders Phase 2: Retrieval, review and synthesis of evidence Phase 3: Testing and refining of the initial programme theory/ ies Phase 4: Actionable recommendations and mobilising of knowledge for use in practice Benefits to the NHS: To inform and guide managers and service leaders about how best to conduct de-implementation in order to ensure health and care services are evidence-based, efficient, and to deliver high quality services for patients which are valued by them.

Lay abstract: In health and care, decisions to stop doing things, where it is clear there is no value or benefit to them, are important. This issue, sometimes called "de-implementation", is very important, with governments across the world taking a very active approach to ensure that the focus is on doing the right things, as well as wasting less resources (such as staff time or money). In Canada, for example, the Choosing Wisely Canada campaign encourages doctors and patients to have conversations about tests, treatments and procedures which may be unnecessary. Italy’s campaign is called Slow Medicine, which provides information for patients and health and care staff about overused procedures, or procedures which do not ultimately benefit the patient. However, stopping people doing things is challenging. However, we often don’t know how to stop people doing things in this way. In fact, little guidance exists to help health and care managers and organisations with making those decisions. The study team have considerable experience in using “realist synthesis”, one of a number of approaches to learning new and different lessons from the many studies already completed on this topic. This approach tries to understand what’s working (in this case, the real-world process of stopping or doing things differently in health and care), how and why things work, and what are the factors that help (or not). The study team is made up of NHS managers (who will provide real life insight into the problem), patient and public representatives (who will ensure the focus of the study reflects those issues which are most important to them), an information scientist, as well as a group of researchers who, collectively, have a track record of undertaking “realist syntheses”. During the study, the team will additionally be guided by a group of people who have interest and expertise in this topic (the stakeholder group) and by a group of senior managers, policy makers and patient and public representatives, who will check and guide the progress of the study (the project advisory group). Our proposed study will be conducted in four phases over 18 months. Phase 1: As different words are used to describe the focus of our study, we will start by developing a robust definition of de-implementation. We will also engage with different stakeholders to learn about their understanding and experiences. Phase 2: We will then do additional searches of different literatures for the relevant evidence about stopping or avoiding practices in health and care. This includes reading reports and organisational documents to help us answer our questions. For example, we may find evidence about the consequences of stopping a practice, where staff find a different way to do things. We will examine this evidence in a methodical way so that we can explain and understand it, using the structure we developed as a guide. Phase 3: We will undertake interviews with managers to learn about the decision- making process in disinvestment or de-implementation processes, and present our findings to the stakeholder group to check if our findings make sense, as an opportunity to clarify and improve them. Phase 4: Our PPI members will co-lead the process of getting the study recommendations to the right people, in order to ensure ways in which to stop and avoid practices are conveyed to a broad audience including managers, health and care staff and the public.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE