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

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.

AIM: To understand the delivery, impact, and acceptability of the EBI programme to produce evidence-based recommendations to optimise future de-adoption efforts. OBJECTIVES: This project will:

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;

c) Explore patients', clinicians', and commissioners' perceptions of the consequences and acceptability of actions taken in response to EBI policies, and d) Co-produce recommendations to support future de-adoption efforts.

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.

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.