Title: Demand Management for Planned Care: A Realist Synthesis
Funder: Department of Health (England)

Abstract: The proposal is for an evidence synthesis and the proposed research strategy is realist synthesis (RS) developed by the chief investigator of this proposal (Pawson 2002; 2006) as a method of systematic review to manage the intricate and uneven bodies of evidence that accrue in primary research on complex interventions. Demand management is one such complex arena which fails to respond well to primary investigation by randomised controlled trial (RCT) or review by formal meta-analysis. Results from a previous SDO-funded investigation on the use Threshold Assessment Grids to improve mental health referrals (Slade et al 2006) illustrate the typical pitfalls. Control group practices outperformed those practices that had introduced the grid. The explanation for the perverse result was the very uneven implementation of the scheme and the very different conditions in which the practices operated. As the authors note ‘the main weakness is the “black-box” assumption embedded in trial methodology’ (2006: 14). All of the multifarious incarnations of demand management allow for and often encourage adaptive implementation and are heavily constrained by local institutional and management regimes. For this reason we have chosen an approach that concentrates on the theories underlying demand management seeking to address their problems and pitfalls and delivering an evidence base which advises on implementation and targeting – what works for whom in what circumstances.RS operates with an iterative study design explained in the detailed project description and summarised here as follows: 1. Identify the review question. The basic unit of analysis in RS is not the intervention but the programme theories that underpin them. The hypotheses that justify the programme and provide the reasons why it might work are also the hypotheses to be investigated in RS. Review thus begins by searching primary materials to identify the justifications arguments and programme logic of the interventions under review. In a complex intervention like demand management these justifications are many and the first stage of an RS is to prioritise those theories whose further investigation is likely to help improve its implementation and targeting. To inform this process we will also hold a theory building workshop with a project reference group of NHS stakeholders as described in the detailed project description attached. 2. Searching for primary studies. Searching is carried out in two main stages. The first described above is the ‘theory search’. Once completed and after the theory to be interrogated has been selected RS commences an ‘evidence search’ seeking studies that will provide empirical tests of each component of the theory. For instance if the theory makes assumptions about the expected reactions of different groups of subjects then primary research is sought that captures the behaviour of those sub-groups. If the theory points to crucial steps required for successful outcomes then research is sought comparing whether this has been implemented across different schemes.3/4. Data extraction and quality appraisal. These phases are combined in RS. Different programme theories require substantiation in divergent bodies of evidence. Hypotheses about the optimal contexts for the intervention are tested in comparative outcome data; claims about the reactions of particular groups of subjects are tested using qualitative data; implementation ideas are tested in process research and so on. Primary studies thus contribute specific bodies of evidence but each primary study plays a different role in the final synthesis and so each fragment of evidence needs to be appraised as it is extracted for both its relevance for theory testing and the rigour with which it has been produced.5. Synthesis. The role of synthesis in RS is not to offer a verdict descriptive summary or mean effect calculation on a family of programmes. Outcomes vary considerably according to how and where programmes are implemented. What is synthesised therefore are all the conditions and caveats that make for programme success. Many of these opportunities and stumbling blocks will have been anticipated in the original programme theories but after a total immersion in the data more refined theories emerge as the key point of synthesis. We will discuss and review our synthesis in a further workshop with our project reference group.6. Dissemination. The purpose of RS is to improve the implementation and targeting of interventions. Accordingly dissemination will focus on NHS decision makers responsible for designing and implementing DM initiatives and these stakeholders will be involved from the outset of the review. Outputs will include actionable guidance to assist NHS decision makers to target and implement demand management initiatives as well as a dissemination event conference presentations and publications in peer reviewed journals as described the at


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE