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With the NHS grappling with constrained resources, the need to produce more value from existing services is crucial. Since 2009, The National Institute of Health and Clinical Excellence (NICE) has been supporting the NHS by identifying “low-value” activities for disinvestment - for example, because they are not clinically effective (and therefore not good value for money), have a close risk/benefit ratio, or they are not supported by adequate evidence. These “low-value” procedures have been brought together to form an online resource of ‘Do not Do’ (DND) technologies. Yet despite such efforts, there is mixed and limited evidence on the value of this approach. Patient preference, diagnostic thresholds used by clinicians, and patients’ and clinicians’ beliefs about the value and efficacy of procedures may influence how these DND recommendations are being implemented. There is likely, therefore to be some variation in how much influence DND recommendations will have in the health system.
As such, this PhD project will focus on further understanding how approaches to disinvestment can be developed, made effective and sustained in the NHS. The project will use the NICE ‘DND’ database as a starting point for identifying ineffective procedures and engage with commissioners, clinicians and patients to qualitatively explore the current barriers which prohibit the effective removal of these interventions in the NHS environment.
“What are the key features underpinning disinvestment strategies and associated clinician behaviours in the NHS?”
This project is based on the assumption that there is a degree of variability in the uptake and implementation of NICE DND recommendations and therefore high geographic variation in clinical procedure rates. We hypothesise that this variation is an indicator that clinicians’ uncertainties may encompass, inter alia (a) the diagnostic and/or treatment thresholds in particular patient subgroups (b) the clinical value attached to the interventions of interest, and that they, therefore, may be using the procedure inappropriately or inefficiently according to current scientific/technology knowledge.
The project involves two stages. Firstly, the NICE DND recommendations will be used as an initial mechanism for identifying ineffective clinical practices and map usage rates geographically to determine if variations in clinical practice exist. Further work will then be undertaken to determine the key mechanisms under-pinning disinvestment strategies and provide a context relevant understanding of how these mechanisms contribute towards variations in clinical practice through a theory-driven realist evaluation.
The realist evaluation will have two stages:
Stage 1 – To identify programme theories around disinvestment (ideas about what enables or constrains effective disinvestment practices)
Stage 2 – To explore the credibility of these programme theories through a mixed-methods approach so that they can be interrogated, endorsed, and/or refined to inform future practice.
In order to achieve this, we will be engaging with individuals who have experience of disinvestment practices in the NHS, who will be asked to complete a survey containing our disinvestment programme theories (the mechanisms thought to enable/constrain disinvestment initiatives, the contexts in which these occur and their intended and unintended outcomes). The survey will be piloted locally to test the sampling strategy before being rolled-out nationally. The data collection instrument will combine tick-boxes and attitudinal questions rated according to Likert scales, with additional opportunities to provide free-text responses also included. The survey will be administered electronically using Survey Monkey.
The disinvestment programme theories will then be re-tested through a series of follow-up semi-structured interviews with survey respondents. This will be done in a pragmatic and reflexive manner to iteratively build on our initial programme theories so that they can be continually endorsed, and/or refined to inform the production of an evaluation framework to aid future de-implementation practices.
For an interim report of this work, please read the NICE Disinvestment Report.
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