Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services

Relevance and flexibility are key: exploring healthcare managers' views and experiences of a de-adoption programme in the English National Health Service

BACKGROUND

De-adoption of healthcare involves stopping or removing provision of an intervention, usually because of concerns about harm, effectiveness, and/or cost-effectiveness. De-adoption is integral to upholding the quality and sustainability of healthcare systems, but can be challenging to achieve. Previous research conducted with healthcare decision-makers identified a desire for more national support to identify and implement de-adoption opportunities. The 'Evidence-Based Interventions' (EBI) programme was a de-adoption programme introduced in the English National Health Service (NHS), comprising national recommendations to guide provision of over 40 healthcare interventions. This study aimed to investigate commissioners' actions in response to this initiative, providing insights to improve the success and impact of future de-adoption programmes.

METHODS

This was a qualitative study, employing in-depth, semi-structured interviews with NHS commissioners. Interviews were analysed thematically using the constant comparison approach. This work was part of a wider mixed-methods study, which aimed to investigate the delivery, impact, and acceptability of the EBI programme across the NHS.

RESULTS

Twenty-five interviews were conducted with 21 commissioners from 7 regions of England. Although commissioners were supportive of the ethos of using evidence-based criteria to guide equitable provision of care, they described inconsistent or limited adoption of EBI recommendations. Commissioners questioned the value and relevance of the recommendations, which often targeted interventions with pre-existing local policies. Local policies often set higher thresholds for accessing interventions, raising concern that adoption of national policies would raise activity to an unsustainable level given strained budgets. Interviews also revealed how implementation of national de-adoption recommendations was not a straightforward process, as they still needed to pass through multi-faceted local ratification processes, which required time, resource, and information/justification that was not always available, making implementation problematic.

CONCLUSION

This study is, to our knowledge, the first investigation of how devolved healthcare policymakers respond to national de-adoption recommendations. Our study highlights that local implementation of national de-adoption policies is not necessarily straightforward, by virtue of the fact that de-adoption concerns entrenched interventions for which devolved policies may already exist. It is therefore critical that national de-adoption initiatives provide guidance around how devolved policymakers should reconcile national recommendations with local policies and processes.

Stakeholders' perspectives on disinvestment of low-value healthcare interventions and practices in Malaysia: an online survey

OBJECTIVES

Healthcare disinvestment requires multi-level decision-making, and early stakeholder engagement is essential to facilitate implementation and acceptance. This study aimed to explore the perceptions of Malaysian healthcare stakeholders to disinvestment initiatives as well as identify disinvestment activities in the country.

METHODS

A cross-sectional online survey was conducted from February to March 2023 among Malaysian healthcare stakeholders involved in resource allocation and decision-making at various levels of governance. Response frequencies were analyzed descriptively and cross-tabulation was performed for specific questions to compare the responses of different groups of stakeholders. For free-text replies, content analysis was used with each verbatim response examined and assigned a theme.

RESULTS

A total of 153 complete responses were analyzed and approximately 37 percent of participants had prior involvement in disinvestment initiatives. Clinical effectiveness and cost-effectiveness ranked as the most important criteria in assessment for disinvestment. Surprisingly, equity was rated the lowest priority despite its crucial role in healthcare decision-making. Almost 90 percent of the respondents concurred that a formal disinvestment framework is necessary and the importance of training for the program's successful implementation. Key obstacles to the adoption of disinvestment include insufficient stakeholder support and political will as well as a lack of expertise in executing the process.

CONCLUSIONS

While disinvestment is perceived as a priority for efficient resource allocation in Malaysian healthcare, there is a lack of a systematic framework for its implementation. Future research should prioritize methodological analysis in healthcare disinvestment and strategies for integrating equity considerations in evaluating disinvestment candidates.

Putting a decommissioning programme into action: an interview study with politicians and public servants in a local healthcare organisation

PURPOSE

A local healthcare organisation providing healthcare to 288,000 residents in Sweden struggled with a longstanding budget deficit. Several attempts to overcome the demanding financial situation have failed. A decommissioning programme was launched, and two years later, an evaluation indicated positive outcomes. The aim of this study was to explore factors politicians and public servants perceived as enablers to the successful implementation of the programme.

DESIGN/METHODOLOGY/APPROACH

A deductive content analysis approach using a framework of factors facilitating successful implementation of decommissioning decisions was applied to analyse interviews with 18 informants.

FINDINGS

Important factors were: (1) a review report contributing to the clarity of evidence, which (2) made the clarity of the rationale for change undeniable and (3) strengthened the political support for change. Additional factors were: (4) the strength of executive leadership, (5) the strength of clinical leadership supported by (6) the quality of project management and (7) a cultural and behavioural change seen as an important outcome for the path forward. A way to maximise the potential for a successful implementation of a large-scale decommissioning programme is to build a shared vision and a collaboration grounded in convincing evidence. Include public servants with a clinical background in the executive leadership team to contribute with legitimacy, competence, and trust in the decommissioning programme's intention.

ORIGINALITY/VALUE

The paper addresses the limited knowledge of best practices in decommissioning processes and contributes empirical knowledge from a successful case.

A New Way of Thinking and Talking About Economy: Clinic Managers' Perspectives on the Sustainable Implementation of a Decommissioning Programme in Sweden

Healthcare systems may run into economic problems that may require 'active' decommissioning by policy-makers and managers. The aim of this study was to investigate, from a sustainability perspective, the implementation of an extensive decommissioning programme in one of the Swedish regions. Interviews were performed with 26 clinic managers 3 years after initial implementation. Those were analysed inductively, and then discussed based on a model of potential influences on sustainability. Although the programme was only 'partly sustained', the result point to a sustained attention to the health system's poor economy, visible in a great effort by the clinics to maintain their budgets. The most important influences were intervention fit and modifications made at the clinic level (i. innovation characteristics), clinic and health system leadership (ii. context), champions (iii. capacity) and shared decision-making and relationship building (iv. processes and interactions). When implementing decommissioning, it is particularly important to engage managers responsible for the care of patients and clinic budgets from an early stage and to allow them to design approaches based on the staff's and managers' detailed knowledge of the situation at their clinics and of the disease area, that is, to achieve fit at the clinics. In this way, the decommissioning approaches can more likely get the character of quality improvement efforts, which increases sustainability and may lead to positive quality outcomes. Despite being unpopular, the study suggests that decommissioning can have positive effects as well, such as creating opportunities to make difficult but necessary changes and fostering increased collegial support during the centralisation of services.

Mid- to late-term follow-up of primary hip and knee arthroplasty: the UK SAFE evidence-based recommendations

To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to ten years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation.

National governance of de-implementation of low-value care: a qualitative study in Sweden

BACKGROUND

The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders' activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC.

METHODS

We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis.

RESULTS

Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation.

CONCLUSIONS

Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.

Market viability: a neglected concept in implementation science

This debate paper asserts that implementation science needs to incorporate a key concept from entrepreneurship—market demand—and demonstrates how assessing an innovation’s potential market viability might advance the pace and success of innovation adoption and sustainment. We describe key concepts, language distinctions, and questions that entrepreneurs pose to implementation scientists—many of which implementation scientists appear ill-equipped to answer. The paper concludes with recommendations about how concepts from entrepreneurship, notably market viability assessment, can enhance the translation of research discoveries into real-world adoption, sustained use, and population health benefits. The paper further proposes activities that can advance implementation science’s capacity to draw from the field of entrepreneurship, along with the data foundations required to assess and cultivate market demand.

Giving patients a voice in Health Technology Assessment decision-making in Greece: a patient advocacy group consensus analysis

Objective

This analysis aimed to assess patient advocacy groups’ (PAGs) perspectives on patients’ and PAGs’ potential role in Health Technology Assessment (HTA) decision-making in Greece.

Methods

In total, 22 representatives of PAGs participated in a consensus panel meeting. Participants’ views were elicited via a consensus panel meeting, through a televoting procedure, based on a structured questionnaire with close-ended questions. Voting was anonymous, to avoid the influence of the dominant personality. After voting, the results were presented to the participants and televoting was repeated to achieve consensus.

Key findings

The majority of participants (94.8%) believe that valid information on the developments regarding HTA in Greece is not conveyed to them by the official national regulatory sources. Key sources of valid information on developments regarding HTA were: conferences (95.2%), international PAGs (85.7%) and HTA experts/scientists (76.2%). About 76.2% of participants evaluated PAGs’ competence to participate in policy-making concerning HTA scheme formation as moderate or higher. Regarding patients’ effective participation in HTA decision-making, greater importance (points 4 and 5 on a 5-point scale) was given to their education on treatment effects in terms of quality of life (100.0%), basic principles of health economics and pharmaceutical policy (95.5%) and ethical aspects of HTA (95.0%). About 55.0% strongly agree that patients should formally express their opinion on HTA issues, while 72.7% believe that patients’ opinions on HTA issues should be expressed through participation in the process and right to vote.

Conclusions

The participation of patients in HTA decision-making is an issue not only of justice but also of essence. For a productive participation, PAGs training is essential.

Factors that shape the successful implementation of decommissioning programmes: an interview study with clinic managers

BACKGROUND

As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization.

METHODS

Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated.

RESULTS

The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process.

CONCLUSIONS

From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

Developing a Model of Care for a 4- to 6-Bedded Postanesthetic Recovery Unit: A Delphi Study

PURPOSE

Recovery units are typically open-plan rooms where all patients can be seen at all times; however, a new hospital has been built with 4- to 6-bed perioperative bays. The purpose of the study was to establish expert consensus regarding problems, benefits, and suggested solutions for the new design across four domains: patient safety, staff satisfaction, organizational efficiency, and maintenance of professional standards.

DESIGN

We conducted a Delphi study to inform the development of a model of care for this new design.

METHODS

A two-round Delphi study involved 71 recovery unit nurses from 13 countries. Problems, solutions, and any potential benefits of the new design were collected in round 1 and ranked in round 2.

FINDINGS

The highest ranked problems were mixing conscious and unconscious patients and need for safe skilled staffing levels. The highest ranked solutions were division of patients, increased safe skilled staffing, and staff education.

CONCLUSIONS

Participants identified clear risks and mitigation strategies. Implementing these strategies should allow for a safer environment for both patients and staff. A model of care to ensure safety and quality in 4- to 6-bedded bay postanesthetic recovery units should address mixing of patients, staffing levels and staff education.

Determinants for the use and de-implementation of low-value care in health care: a scoping review

BACKGROUND

A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC.

AIM

The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care.

METHODS

A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group.

RESULTS

In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research.

CONCLUSION

The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC.

REGISTRATION

The review has not been registered.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis

Background

Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.

Objectives

Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.

Design

A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.

Participants

In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.

Data sources

Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.

Results

The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.

Limitations

Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.

Conclusions

This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.

Study registration

This study is registered as PROSPERO CRD42017081030.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Austerity on the frontline- a preliminary study of physiotherapists working in the National Health Service in the UK

BACKGROUND

Organizational reform has been commonplace in the response to global socio-economic changes. Rising managerialism, consumerism and marketization has accelerated reforms; providing challenges for the healthcare professions. The latest socio-economic challenge, austerity, and its professional implications have scarcely been researched. This study aims to explore the lived reality of austerity as experienced by physiotherapists working on the frontline of the National Health Service (NHS) in the UK.

METHODS

Ethical approval was granted by the University of Nottingham; the study was advertised via the Chartered Society of Physiotherapy online network. Two participants took part; semi-structured interviews were completed, audio recorded, and transcribed. Data was analyzed using thematic analysis.

FINDINGS

Three themes arose from the data: (1) Fulfilling professional responsibilities; (2) Changing organizational landscape; and (3) Professional reality of rationalizing and accommodating austerity. The clinical implications of austerity included increased length of hospital stay, insufficient community services, constrained resources, and understaffing. Participants demonstrated attempts to preserve their professional status and services through restratification throughout the intra-professional hierarchy, changing division of labor, and re-professionalization.

CONCLUSIONS

Despite claims that austerity is coming to an end, it remained a reality for these clinicians in the NHS. Physiotherapists in this study used similar methods to preserve practice when faced with exogenous constraints as seen in medicine, such as re-professionalization and restratification. However, this attempt to defend professionalism by a non-medical healthcare profession was met with both successes and losses and has implications for the wider healthcare profession ecology, identifying an area for future research.

Awareness and opinions on healthcare decommissioning in a Swedish region

Decision-makers may have to decommission services as a response to budget deficits. The aim of this study was to investigate a case of decommissioning with regard to the public's awareness and opinions. The analysis of a survey in a Swedish region that begun the implementation of an extensive decommissioning programme in 2015 shows that the majority of respondents were well or very well informed about the programme (68 %). A large proportion of the respondents thought the decision-makers to a low or very low degree had adopted appropriate measures to solve the economic problems (43 %), but together more respondents were either indifferent (39.5 %) or positive (17.5 %). Regarding the level of satisfaction with the region's healthcare system, compared to prior to the decommissioning period, 30 % were less satisfied while together more were either indifferent (48 %) or had become more satisfied (22 %). The large share of indifferent responses opens up for various interpretations or framings of the programme outcomes. Trust in the regions' healthcare system nevertheless increased during the same period. Furthermore, self-assessed health as well as age and utilization seem to be associated with healthcare system satisfaction during decommissioning. This illustrates heterogeneity in the public's responses to decommissioning, which calls for further investigation.

Decommissioning in a local healthcare system in Sweden: responses to fiscal stress

BACKGROUND

Drawing on the literature on cutback management, this article deals with healthcare decommissioning in times of austerity. Politicians and decision-makers are typically reluctant to decommission healthcare, and if they do, the public generally reacts strongly towards reductions in service supply. Despite this, comprehensive decommissioning does take place, though empirical knowledge about its effects and economic sustainability is limited. To further the understanding of healthcare decommissioning, this paper aims to introduce the concepts of cutback management into the research on healthcare decommissioning, and apply its components to an empirical case of comprehensive decommissioning. In doing so, the study analyses whether decommissioning measures can be expected to generate long- or short-term economic payoff, and considers what other effects they might have on the healthcare system.

METHOD

We developed a theoretical framework that enabled us to investigate the measures through which a local healthcare system in Sweden, region Dalarna, responded to an acute fiscal crisis in 2014, and what effects these measures are likely to generate. The method used was a deductive content analysis of Dalarna's decommissioning program, containing 122 austerity measures for saving 700 million Swedish Krona (SEK).

RESULTS

Dalarna's local decision-makers responded to the fiscal crisis through a combination of operational cuts (20% of undertaken measures), programme cuts (42% of undertaken measures), and structural reforms (38% of undertaken measures). The instruments most commonly used were increased patient fees and the merger of service facilities. By relying foremost on programme cuts and structural reforms, Dalarna adopted the measures most plausible to have moderate or long-term economic payoffs. Successful implementation, however, may be challenging and difficult to evaluate.

CONCLUSIONS

Healthcare politicians and decision makers have better potential to stabilize their long-term economic situation if they rely on responses such as operational cuts, programme cuts and structural reforms, as opposed to across-the-board cuts and cuts in investment and capital expenditures. However, with economics being only one important factor for sustainable healthcare systems, further studies should investigate how these measures affect important principles, such as equal healthcare distribution and access.

TRIAL REGISTRATION

Not applicable.

De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations.

OBJECTIVE

We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative.

DESIGN

We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys.

PARTICIPANTS

We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems.

MAIN MEASURES

Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared.

KEY RESULTS

Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate.

CONCLUSIONS

Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.

To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol

BACKGROUND

Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.

METHODS

Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.

DISCUSSION

This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

Towards UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): protocol for an evaluation of the requirements for arthroplasty follow-up, and the production of consensus-based recommendations

INTRODUCTION

Hip and knee arthroplasties have revolutionised the management of degenerative joint diseases and, due to an ageing population, are becoming increasingly common. Follow-up of joint prostheses is to identify problems in symptomatic or asymptomatic patients due to infection, osteolysis, bone loss or potential periprosthetic fracture, enabling timely intervention to prevent catastrophic failure at a later date. Early revision is usually more straight-forward surgically and less traumatic for the patient. However, routine long-term follow-up is costly and requires considerable clinical time. Therefore, some centres in the UK have curtailed this aspect of primary hip and knee arthroplasty services, doing so without an evidence base that such disinvestment is clinically or cost-effective.

METHODS

Given the timeline from joint replacement to revision, conducting a randomised controlled trial (RCT) to determine potential consequences of disinvestment in hip and knee arthroplasty follow-up is not feasible. Furthermore, the low revision rates of modern prostheses, less than 10% at 10 years, would necessitate thousands of patients to adequately power such a study. The huge variation in follow-up practice across the UK also limits the generalisability of an RCT. This study will therefore use a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Four interconnected work packages will be completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from five national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up care for an individual patient.

ETHICS AND DISSEMINATION

Favourable ethical opinion has been obtained for WP2a (RO-HES) (220520) and WP2B (220316) from the National Research Ethics Committee. Following advice from the Confidentiality Advisory Group (17/CAG/0122), data controllers for the data sets used in WP2a (RO-HES) - NHS Digital and The Phoenix Partnership - confirmed that Section 251 support was not required as no identifiable data was flowing into or out of these parties. Application for approval of WP2a (RO-HES) from the Independent Group Advising on the Release of Data (IGARD) at NHS Digital is in progress (DARS-NIC-147997). Section 251 support (17/CAG/0030) and NHS Digital approval (DARS-NIC-172121-G0Z1H-v0.11) have been obtained for WP2a (NJR-HES-PROMS). ISAC (11_050MnA2R2) approval has been obtained for WP2a (CPRD-HES).

Reports of rationing from the neglected realm of capital investment: Responses to resource constraint in the English National Health Service

Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study

PURPOSE

The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented.

DESIGN/METHODOLOGY/APPROACH

A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments.

FINDINGS

The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people.

RESEARCH LIMITATIONS/IMPLICATIONS

Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input.

PRACTICAL IMPLICATIONS

The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems.

ORIGINALITY/VALUE

This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

Changing behaviour 'more or less'-do theories of behaviour inform strategies for implementation and de-implementation? A critical interpretive synthesis

BACKGROUND

Implementing evidence-based care requires healthcare practitioners to do less of some things (de-implementation) and more of others (implementation). Variations in effectiveness of behaviour change interventions may result from failure to consider a distinction between approaches by which behaviour increases and decreases in frequency. The distinction is not well represented in methods for designing interventions. This review aimed to identify whether there is a theoretical rationale to support this distinction.

METHODS

Using Critical Interpretative Synthesis, this conceptual review included papers from a broad range of fields (biology, psychology, education, business) likely to report approaches for increasing or decreasing behaviour. Articles were identified from databases using search terms related to theory and behaviour change. Articles reporting changes in frequency of behaviour and explicit use of theory were included. Data extracted were direction of behaviour change, how theory was operationalised, and theory-based recommendations for behaviour change. Analyses of extracted data were conducted iteratively and involved inductive coding and critical exploration of ideas and purposive sampling of additional papers to explore theoretical concepts in greater detail.

RESULTS

Critical analysis of 66 papers and their theoretical sources identified three key findings: (1) 9 of the 15 behavioural theories identified do not distinguish between implementation and de-implementation (5 theories were applied to only implementation or de-implementation, not both); (2) a common strategy for decreasing frequency was substituting one behaviour with another. No theoretical basis for this strategy was articulated, nor were methods proposed for selecting appropriate substitute behaviours; (3) Operant Learning Theory makes an explicit distinction between techniques for increasing and decreasing frequency.

DISCUSSION

Behavioural theories provide little insight into the distinction between implementation and de-implementation. Operant Learning Theory identified different strategies for implementation and de-implementation, but these strategies may not be acceptable in health systems. Additionally, if behaviour substitution is an approach for de-implementation, further investigation may inform methods or rationale for selecting the substitute behaviour.

Appraising the Evidence Supporting Choosing Wisely® Recommendations

Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (IQR 33.3%-70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%-83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.

Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis

BACKGROUND

Decisions affecting cost and quality are taken across health and care but investigation of the mediating role of context in these is in its infancy. This paper presents a synthesis of the evidence on the contextual factors that influence 'decisions of value' - defined as those characterised by having a significant and demonstrable impact on both quality and resources - in health and care. The review considers the full range of resource/quality decisions and synthesises knowledge on the contextual drivers of these.

METHODS

The method involved structured evidence review and narrative synthesis. Literature was identified through searches of electronic databases (HMIC, Medline, Embase, CINAHL, NHS Evidence, Cochrane, Web of Knowledge, ABI Inform/Proquest), journal and bibliography hand-searching and snowball searching using citation analysis. Structured data extraction was performed drawing out descriptive information and content against review aims and questions. Data synthesis followed a thematic approach in accordance with the varied nature of the retrieved literature.

RESULTS

Twenty-one literature items reporting 14 research studies and seven literature reviews met the inclusion criteria. The review shows that in health and care contexts, research into decisions of value in health and care is in its infancy and contains wide variation in approach and remit. The evidence is drawn from a range of service and country settings and this reduces generalisability or transferability of findings. An area of relative strength in the published evidence is inquiry into factors influencing coverage and commissioning decisions in health care systems. Allocative decisions have therefore been more consistently researched than technical decisions. We use Pettigrew's (1985) distinction between inner and outer context to structure analysis of the range of factors reported as being influential. These include: evidence/information, organisational culture and governance regimes, and; economic and political conditions.

CONCLUSION

Decisions of value in health and care are subject to range of intersecting influences that often lead to a departure from narrow notions of rational decision-making. Future research should pay greater attention to the relatively under-explored area of technical, as opposed to allocative, decision-making.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 11: reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting

Background

This is the final paper in a thematic series reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was established to explore a systematic, integrated, evidence-based organisation-wide approach to disinvestment in a large Australian health service network. This paper summarises the findings, discusses the contribution of the SHARE Program to the body of knowledge and understanding of disinvestment in the local healthcare setting, and considers implications for policy, practice and research.

Discussion

The SHARE program was conducted in three phases. Phase One was undertaken to understand concepts and practices related to disinvestment and the implications for a local health service and, based on this information, to identify potential settings and methods for decision-making about disinvestment. The aim of Phase Two was to implement and evaluate the proposed methods to determine which were sustainable, effective and appropriate in a local health service. A review of the current literature incorporating the SHARE findings was conducted in Phase Three to contribute to the understanding of systematic approaches to disinvestment in the local healthcare context.

SHARE differed from many other published examples of disinvestment in several ways: by seeking to identify and implement disinvestment opportunities within organisational infrastructure rather than as standalone projects; considering disinvestment in the context of all resource allocation decisions rather than in isolation; including allocation of non-monetary resources as well as financial decisions; and focusing on effective use of limited resources to optimise healthcare outcomes.

Conclusion

The SHARE findings provide a rich source of new information about local health service decision-making, in a level of detail not previously reported, to inform others in similar situations. Multiple innovations related to disinvestment were found to be acceptable and feasible in the local setting. Factors influencing decision-making, implementation processes and final outcomes were identified; and methods for further exploration, or avoidance, in attempting disinvestment in this context are proposed based on these findings. The settings, frameworks, models, methods and tools arising from the SHARE findings have potential to enhance health care and patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3172-0) contains supplementary material, which is available to authorized users.

Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol

Background

A considerable proportion of interventions provided to patients lacks evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary, or even harmful care. Thus, in addition to implementing evidence-based practices, there is also a need to abandon interventions that are not based on best evidence, i.e., low-value care. However, research on de-implementation is limited, and there is a lack of knowledge about how effective de-implementation processes should be carried out. The aim of this project is to explore the phenomenon of the de-implementation of low-value health care practices from the perspective of professionals and the health care system.

Methods

Theories of habits and developmental learning in combination with theories of organizational alignment will be used. The project’s work will be conducted in five steps. Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders. Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de-implementation. In Step 4, a conceptual framework for de-implementation will be developed based on the previous steps. In Step 5, strategies for de-implementation are identified using a co-design approach.

Discussion

This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de-implementation of low-value care. The professionals’ perspectives will be highlighted, including insights into how they make decisions, handle de-implementation in daily practice, and what consequences it has on their work. Furthermore, the health care system perspective will be considered and new knowledge on how de-implementation can be understood across health care system levels will be obtained. The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve de-implementation processes at all levels of the health care system. The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

What Factors Do Allied Health Take Into Account When Making Resource Allocation Decisions?

BACKGROUND

Allied health comprises multiple professional groups including dietetics, medical radiation practitioners, occupational therapists, optometrists and psychologists. Different to medical and nursing, Allied health are often organized in discipline specific departments and allocate budgets within these to provide services to a range of clinical areas. Little is known of how managers of allied health go about allocating these resources, the factors they consider when making these decisions, and the sources of information they rely upon. The purpose of this study was to identify the key factors that allied health consider when making resource allocation decisions and the sources of information they are based upon.

METHODS

Four forums were conducted each consisting of case studies, a large group discussion and two hypothetical scenarios to elicit data. A thematic content analysis commenced during post-forum discussions of key factors by forum facilitators. These factors were then presented to an expert working party for further discussion and refinement. Transcripts were generated of all data recordings and a detailed thematic analysis was undertaken by one author to ensure coded data matched the initial thematic analysis.

RESULTS

Twelve factors affecting the decision-making of allied health managers and clinicians were identified. One of these factors was disendorsed by the expert working party. The 11 remaining factors can be considered to be key decision-making principles that should be consistently applied to resource allocation. These principles were clustered into three overarching themes of readiness, impact and appropriateness.

CONCLUSION

Understanding these principles now means further research can be completed to more effectively integrate research evidence into health policy and service delivery, create partnerships among policy-makers, managers, service providers and researchers, and to provide support to answer difficult questions that policy-makers, managers and service providers face.

De-implementation: A concept analysis

AIM

The purpose of this concept analysis is to explore the meaning of de-implementation and provide a definition that can be used by researchers and clinicians to facilitate evidence-based practice.

BACKGROUND

De-implementation is a relatively unknown process overshadowed by the novelty of introducing new ideas and techniques into practice. Few studies have addressed the challenge of de-implementation and the cognitive processes involved when terminating harmful or unnecessary practices. Also, confusion exists regarding the myriad of terms used to describe de-implementation processes.

DESIGN

Walker and Avant's method (2011) for describing concepts was used to clarify de-implementation.

DATA SOURCE

A database search limited to academic journals yielded 281 publications representing basic research, study protocols, and editorials/commentaries from implementation science experts. After applying exclusion criterion of English language only and eliminating overlap between databases, 41 articles were selected for review.

REVIEW METHODS

Literature review and synthesis provided a concept analysis and a distinct definition of de-implementation.

RESULTS

De-implementation was defined as the process of identifying and removing harmful, non-cost-effective, or ineffective practices based on tradition and without adequate scientific support.

CONCLUSIONS

The analysis provided further refinement of de-implementation as a significant concept for ongoing theory development in implementation science and clinical practice.

Past, present and future challenges in health care priority setting

Purpose Current conditions have intensified the need for health systems to engage in the difficult task of priority setting. As the search for a "magic bullet" is replaced by an appreciation for the interplay between evidence, interests, culture, and outcomes, progress in relation to these dimensions requires assessment of achievements to date and identification of areas where knowledge and practice require attention most urgently. The paper aims to discuss these issues. Design/methodology/approach An international survey was administered to experts in the area of priority setting. The survey consisted of open-ended questions focusing on notable achievements, policy and practice challenges, and areas for future research in the discipline of priority setting. It was administered online between February and March of 2015. Findings "Decision-making frameworks" and "Engagement" were the two most frequently mentioned notable achievements. "Priority setting in practice" and "Awareness and education" were the two most frequently mentioned policy and practical challenges. "Priority setting in practice" and "Engagement" were the two most frequently mentioned areas in need of future research. Research limitations/implications Sampling bias toward more developed countries. Future study could use findings to create a more concise version to distribute more broadly. Practical implications Globally, these findings could be used as a platform for discussion and decision making related to policy, practice, and research in this area. Originality/value Whilst this study reaffirmed the continued importance of many longstanding themes in the priority setting literature, it is possible to also discern clear shifts in emphasis as the discipline progresses in response to new challenges.

How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

RATIONALE AND OBJECTIVES

One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.

RESULTS

We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.

CONCLUSIONS

By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting

BACKGROUND

This is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective.

DISCUSSION

Four themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment. There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term 'disinvestment' should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches. The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed. A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon. The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers. There is little evidence of successful implementation of 'disinvestment' projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs.

CONCLUSIONS

These findings suggest that the construct of 'disinvestment' may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation

Background

This is the tenth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. After more than a decade of research, there is little published evidence of active and successful disinvestment. The paucity of frameworks, methods and tools is reported to be a factor in the lack of success. However there are clear and consistent messages in the literature that can be used to inform development of a framework for operationalising disinvestment. This paper, along with the conceptual review of disinvestment in Paper 9 of this series, aims to integrate the findings of the SHARE Program with the existing disinvestment literature to address the lack of information regarding systematic organisation-wide approaches to disinvestment at the local health service level.

Discussion

A framework for disinvestment in a local healthcare setting is proposed. Definitions for essential terms and key concepts underpinning the framework have been made explicit to address the lack of consistent terminology. Given the negative connotations of the word ‘disinvestment’ and the problems inherent in considering disinvestment in isolation, the basis for the proposed framework is ‘resource allocation’ to address the spectrum of decision-making from investment to disinvestment. The focus is positive: optimising healthcare, improving health outcomes, using resources effectively.

The framework is based on three components: a program for decision-making, projects to implement decisions and evaluate outcomes, and research to understand and improve the program and project activities. The program consists of principles for decision-making and settings that provide opportunities to introduce systematic prompts and triggers to initiate disinvestment. The projects follow the steps in the disinvestment process. Potential methods and tools are presented, however the framework does not stipulate project design or conduct; allowing application of any theories, methods or tools at each step. Barriers are discussed and examples illustrating constituent elements are provided.

Conclusions

The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2506-7) contains supplementary material, which is available to authorized users.

Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study

Background

Decommissioning – defined as the planned process of removing, reducing or replacing health-care services – is an important component of current reforms in the NHS. However, the evidence base on which to guide policy and practice in this area is weak.

Aim

This study aims to formulate theoretically grounded, evidence-informed guidance to support best practice in effective decommissioning of NHS services.

Design

The overall approach is a sequential, multimethod research design. The study involves (1) a literature synthesis summarising what is known about decommissioning, an international expert Delphi study, 12 interviews with national/regional bodies and seven narrative vignettes from NHS leaders; (2) a survey of Clinical Commissioning Groups (CCGs) in England (n = 56/211, 27%); (3) longitudinal, prospective case studies of four purposively sampled decommissioning projects comprising 59 semistructured interviews, 18 non-participant observations and documentary analysis; and (4) research with citizens, patient/service user representatives, carers, third-sector organisations and local community groups, including three focus groups (30 participants) and a second Delphi study (26 participants). The study took place over the period 2013–16.

Setting

The English NHS.

Results

There is a lack of robust evidence to guide decommissioning, but among experts there is a high level of consensus for the following good-practice principles: establish a strong leadership team, engage clinical leaders from an early stage and establish a clear rationale for change. The most common type of CCG decommissioning activity was ‘relocation or replacement of a service from an acute to a community setting’ (28% of all activities) and the majority of responding CCGs (77%) were planning to decommission services. Case studies demonstrate the need to (1) draw on evidence, reviews and policies to frame the problem; (2) build alliances in order to legitimise decommissioning as a solution; (3) seek wider acceptance, including among patients and community groups, of decommissioning; and (4) devise implementation plans that recognise the additional challenges of removal and replacement. Citizens, patient/service user representatives, carers, third-sector organisations and local community groups were more likely to believe that decommissioning is driven by financial and political concerns than by considerations of service quality and efficiency, and to distrust and/or resent decision-makers. Overall, the study suggests that failure rates in decommissioning are likely to be higher than in other forms of service change, suggesting the need for tailored design and implementation approaches.

Limitations

There were few opportunities for patient and public engagement in early phases of the research; however, this was mitigated by the addition of work package 4. We were unable to track outcomes of decommissioning activities within the time scales of the project and the survey response rate was lower than anticipated.

Conclusions

Decommissioning is shaped by change management and implementation, evidence and information, and relationships and politics. We propose an expanded understanding, encompassing organisational and political factors, of how avoidance of loss affects the delivery of decommissioning programmes. Future work should explore the relationships between contexts, mechanisms and outcomes in decommissioning, develop the understanding of how loss affects decisions and explore the long-term impact of decommissioning and its impact on patient care and outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 7: supporting staff in evidence-based decision-making, implementation and evaluation in a local healthcare setting

BACKGROUND

This is the seventh in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for resource allocation within a large Australian health service. It aimed to facilitate proactive use of evidence from research and local data; evidence-based decision-making for resource allocation including disinvestment; and development, implementation and evaluation of disinvestment projects. From the literature and responses of local stakeholders it was clear that provision of expertise and education, training and support of health service staff would be required to achieve these aims. Four support services were proposed. This paper is a detailed case report of the development, implementation and evaluation of a Data Service, Capacity Building Service and Project Support Service. An Evidence Service is reported separately.

METHODS

Literature reviews, surveys, interviews, consultation and workshops were used to capture and process the relevant information. Existing theoretical frameworks were adapted for evaluation and explication of processes and outcomes.

RESULTS

Surveys and interviews identified current practice in use of evidence in decision-making, implementation and evaluation; staff needs for evidence-based practice; nature, type and availability of local health service data; and preferred formats for education and training. The Capacity Building and Project Support Services were successful in achieving short term objectives; but long term outcomes were not evaluated due to reduced funding. The Data Service was not implemented at all. Factors influencing the processes and outcomes are discussed.

CONCLUSION

Health service staff need access to education, training, expertise and support to enable evidence-based decision-making and to implement and evaluate the changes arising from those decisions. Three support services were proposed based on research evidence and local findings. Local factors, some unanticipated and some unavoidable, were the main barriers to successful implementation. All three proposed support services hold promise as facilitators of EBP in the local healthcare setting. The findings from this study will inform further exploration.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting

BACKGROUND

This is the sixth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE program was established to investigate a systematic, integrated, evidence-based approach to disinvestment within a large Australian health service. This paper describes the methods employed in undertaking pilot disinvestment projects. It draws a number of lessons regarding the strengths and weaknesses of these methods; particularly regarding the crucial first step of identifying targets for disinvestment.

METHODS

Literature reviews, survey, interviews, consultation and workshops were used to capture and process the relevant information. A theoretical framework was adapted for evaluation and explication of disinvestment projects, including a taxonomy for the determinants of effectiveness, process of change and outcome measures. Implementation, evaluation and costing plans were developed.

RESULTS

Four literature reviews were completed, surveys were received from 15 external experts, 65 interviews were conducted, 18 senior decision-makers attended a data gathering workshop, 22 experts and local informants were consulted, and four decision-making workshops were undertaken. Mechanisms to identify disinvestment targets and criteria for prioritisation and decision-making were investigated. A catalogue containing 184 evidence-based opportunities for disinvestment and an algorithm to identify disinvestment projects were developed. An Expression of Interest process identified two potential disinvestment projects. Seventeen additional projects were proposed through a non-systematic nomination process. Four of the 19 proposals were selected as pilot projects but only one reached the implementation stage. Factors with potential influence on the outcomes of disinvestment projects are discussed and barriers and enablers in the pilot projects are summarised.

CONCLUSION

This study provides an in-depth insight into the experience of disinvestment in one local healthcare service. To our knowledge, this is the first paper to report the process of disinvestment from identification, through prioritisation and decision-making, to implementation and evaluation, and finally explication of the processes and outcomes.

Sustainability in health care by allocating resources effectively (SHARE) 3: examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting

Background

This is the third in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Leaders in a large Australian health service planned to establish an organisation-wide, systematic, integrated, evidence-based approach to disinvestment. In order to introduce new systems and processes for disinvestment into existing decision-making infrastructure, we aimed to understand where, how and by whom resource allocation decisions were made, implemented and evaluated. We also sought the knowledge and experience of staff regarding previous disinvestment activities.

Methods

Structured interviews, workshops and document analysis were used to collect information from multiple sources in an environmental scan of decision-making systems and processes. Findings were synthesised using a theoretical framework.

Results

Sixty-eight respondents participated in interviews and workshops. Eight components in the process of resource allocation were identified: Governance, Administration, Stakeholder engagement, Resources, Decision-making, Implementation, Evaluation and, where appropriate, Reinvestment of savings. Elements of structure and practice for each component are described and a new framework was developed to capture the relationships between them. A range of decision-makers, decision-making settings, type and scope of decisions, criteria used, and strengths, weaknesses, barriers and enablers are outlined. The term ‘disinvestment’ was not used in health service decision-making. Previous projects that involved removal, reduction or restriction of current practices were driven by quality and safety issues, evidence-based practice or a need to find resource savings and not by initiatives where the primary aim was to disinvest. Measuring resource savings is difficult, in some situations impossible. Savings are often only theoretical as resources released may be utilised immediately by patients waiting for beds, clinic appointments or surgery. Decision-making systems and processes for resource allocation are more complex than assumed in previous studies.

Conclusion

There is a wide range of decision-makers, settings, scope and type of decisions, and criteria used for allocating resources within a single institution. To our knowledge, this is the first paper to report this level of detail and to introduce eight components of the resource allocation process identified within a local health service.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2207-2) contains supplementary material, which is available to authorized users.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting

Background

This is the second in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Rising healthcare costs, continuing advances in health technologies and recognition of ineffective practices and systematic waste are driving disinvestment of health technologies and clinical practices that offer little or no benefit in order to maximise outcomes from existing resources. However there is little information to guide regional health services or individual facilities in how they might approach disinvestment locally. This paper outlines the investigation of potential settings and methods for decision-making about disinvestment in the context of an Australian health service.

Methods

Methods include a literature review on the concepts and terminology relating to disinvestment, a survey of national and international researchers, and interviews and workshops with local informants. A conceptual framework was drafted and refined with stakeholder feedback.

Results

There is a lack of common terminology regarding definitions and concepts related to disinvestment and no guidance for an organisation-wide systematic approach to disinvestment in a local healthcare service.

A summary of issues from the literature and respondents highlight the lack of theoretical knowledge and practical experience and provide a guide to the information required to develop future models or methods for disinvestment in the local context.

A conceptual framework was developed. Three mechanisms that provide opportunities to introduce disinvestment decisions into health service systems and processes were identified. Presented in order of complexity, time to achieve outcomes and resources required they include 1) Explicit consideration of potential disinvestment in routine decision-making, 2) Proactive decision-making about disinvestment driven by available evidence from published research and local data, and 3) Specific exercises in priority setting and system redesign.

Conclusion

This framework identifies potential opportunities to initiate disinvestment activities in a systematic integrated approach that can be applied across a whole organisation using transparent, evidence-based methods. Incorporating considerations for disinvestment into existing decision-making systems and processes might be achieved quickly with minimal cost; however establishment of new systems requires research into appropriate methods and provision of appropriate skills and resources to deliver them.

Electronic supplementary material

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