Title: A mixed-methods investigation of the delivery, impact and acceptability of a national de-adoption programme across Clinical Commissioning Groups in the English National Health Service
Funder: Department of Health and Social Care

Abstract: The National Health Service (NHS) is under pressure to deliver high quality care with limited funds. As research progresses, evidence emerges to suggest some commonly used treatments are not as beneficial as previously thought, either in some or all patients. Stopping or reducing such treatments can release funds for more beneficial care and reduce harm. Stopping or reducing a treatment that is currently available is referred to as 'de-adoption'. De-adoption could mean stopping a treatment altogether, or only providing it for patients expected to benefit. In 2019, NHS England launched the Evidence-based Interventions (EBI) Programme. This named 17 surgical procedures that NHS commissioners are required to stop funding, or only fund if patients fulfil criteria stated in the EBI policies. Our project aims to understand the delivery, impact, and acceptability of the EBI programme, in order to produce recommendations to improve future efforts to reduce care shown to be of limited benefit. We will achieve this through three Work Packages._x000D_ _x000D_ Work package 1 examines changes in NHS care before and after EBI policies were issued. We will study changes in numbers of operations performed for each EBI procedure and changes in other operations that may be done instead. We will study some procedures (e.g. shoulder and hand surgery) in detail, by examining changes in numbers of referrals to specialists, GP appointments, prescriptions, and time spent waiting for referral to hospital. This will help us understand wider impacts of reducing the surgical procedures. _x000D_ _x000D_ Work package 2 will explore what happened in response to the EBI programme. We will focus the research on the above procedures, in geographic areas that reduced numbers for these operations, and areas that did not. We will interview commissioners, GPs, and specialists to understand what actions were taken in response to EBI policies, and their views about the consequences and acceptability of these actions. We will also interview patients being considered for surgery to explore their experiences and satisfaction with care, and audio-record clinical consultations where the procedures are discussed with patients to study what happens in front-line care. We will examine a wide selection of regional NHS policies for accessing the EBI procedures, and send a survey to commissioners across England to capture actions taken in response to the EBI programme. _x000D_ _x000D_ Work Package 3 will combine results from the research above and consider findings in relation to other evidence. We will work with patients, clinicians, commissioners, and policy makers to write recommendations for timely and acceptable de-adoption of future care that is found to be of little benefit, based on our understandings of the actions and consequences of de-adoption through the EBI programme. _x000D_ _x000D_ A Patient and Public Advisory Group will support delivery of the research by helping to design documents inviting people to take part in the study, reviewing interview questions, interpreting study data, and co-producing recommendations. Findings will be presented in academic articles, funder reports, videos, conferences, talks with NHS England, and a public engagement event. The Patient and Public Advisory group and clinicians, commissioners, and policy leaders we have involved in designing this research will support the spread of findings to ensure long-term impact.

Lay abstract: BACKROUND: The National Health Service is under intense pressure to maintain and improve services with limited funds. New evidence relating to currently adopted treatments can sometimes raise questions about the benefits of continued provision– either in general, or for particular patient groups. 'De-adoption' refers to stopping or restricting the scale of treatments currently used in practice. NHS England launched the Evidence-based Interventions (EBI) Programme in 2019, identifying 17 surgical procedures that regional commissioning bodies should stop routinely funding, or only fund if patients meet set criteria. Initiatives of this scale are vital to sustaining health systems, but de-adoption attempts often fail and evidence to guide efforts is limited. _x000D_ _x000D_ AIM: To understand the delivery, impact, and acceptability of the EBI programme to produce evidence-based recommendations to optimise future de-adoption efforts. _x000D_ _x000D_ OBJECTIVES: This project will: _x000D_ a) Examine changes in EBI procedure rates and costs, spillover effects on related procedures, and changes in care pathways before and after EBI policy publication; b) Investigate actions taken in geographic localities (the ‘meso-level’) in response to national EBI policies; _x000D_ c) Explore patients', clinicians', and commissioners' perceptions of the consequences and acceptability of actions taken in response to EBI policies, and _x000D_ d) Co-produce recommendations to support future de-adoption efforts. _x000D_ _x000D_ DESIGN AND METHODS: Objectives will be addressed using mixed-methods across 3 Work Packages (WPs) and a fully integrated Patient and Public Advisory Group (PPAG). WP1 (objective 'a') uses Hospital Episode Statistics (HES) data to examine changes in activity for the EBI procedures before and after EBI policies were issued, and changes in potential 'related procedures' patients may be receiving instead. Clinical Practice Research Database-HES linked data will be used to examine changes in care pathways for two procedures in more detail (e.g. changes in numbers of referrals, non-surgical treatments, and time to referral). WP2 investigates actions taken in response to the EBI policies within select regions (objective 'b'), and stakeholders' perceptions of the consequences and acceptability of these actions (objective 'c'). It comprises: i) content analysis of regional commissioning policies for accessing EBI procedures; ii) qualitative interviews in regions with high and low levels of activity reduction for select procedures, to understand actions taken in response to EBI policies, and commissioners', clinicians', and patients' views on the acceptability of these actions, iii) audio-recordings of clinical consultations in which the procedures from 'ii' are discussed with patients, and iv) a national survey to capture commissioners’ actions in response to EBI policies. WP3 will entail synthesising findings and presenting these to stakeholders (PPAG, clinicians, commissioners, and national policy leads), with a view to co-producing recommendations to optimise future de-adoption efforts. _x000D_ _x000D_ DISSEMINATION/IMPACT: We will produce evidence-informed recommendations to support de-adoption of care found to be of limited benefit, and disseminate findings through journal articles, NIHR reports, animations, conferences , public engagement events, talks to policy leaders and CCG webinars. The PPAG, commissioners, clinical and policy leaders have been involved since the project's conception and are committed to supporting dissemination for sustained impact.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE