Developing the NHS long term plan: evidence based interventions

Developing the NHS long term plan: evidence based interventions
NHS England Board paper 4 July 2018

• NHS England will consult on the Evidence-Based Interventions programme, developed and jointly led by NHS England, NICE, NHS Improvement, the Academy of Medical Royal Colleges, and NHS Clinical Commissioners. 
• The focus of the programme is on surgical interventions commissioned by CCGs, where there was high variability in the application of clinical guidelines. 
• Priority was given to changes which could test the approach and implement relatively quickly on a large scale. 
• The consultation proposes that four interventions (Category 1) that should no longer be routinely commissioned by CCGs unless accompanied by a successful Individual Funding Request (IFR) and 13 interventions (Category 2) that should only be commissioned by CCGs or performed when specific evidence based clinical criteria are met. It is proposed that Category 1 interventions will be set at zero tariff in National Tariff without a successful IFR. 

New patient care test for hospital bed closures

New patient care test for hospital bed closures
NHS England 3 March 2017

• From April 1, local NHS organisations will have to show that significant hospital bed closures subject to the current formal public consultation tests can meet one of three new conditions before NHS England will approve them to go ahead:
• Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or
• Show that specific new treatments or therapies, such as new anti-coagulation drugs used to treat strokes, will reduce specific categories of admissions; or
• Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting it Right First Time programme)
• The announcement builds on the four existing tests for reconfiguration put in place in 2010. Under those rules, closures can only go ahead with support from GP commissioners, strengthened public and patient engagement, clear clinical evidence and provided that they are consistent with patient choice.

"Do no do" recommendations from Royal Colleges

Forty treatments that bring little or no benefit to patients
Academy of Medical Royal Colleges 24 October 2016

• The AoMRCs has compiled 40 recommendations from Royal Colleges of treatments that bring little or no benefit to patients. 
• This is core to their Choosing Wisely initiative which calls doctors and patients to have a fully informed conversation about the risks and benefits of treatments and procedures.
• The complete list of recommendations can be found on the Choose Wisely website here.
• See also AMRC launches Choosing Wisely programme

A framework to facilitiate de-adoption of low value clinical procedures

Towards understanding the de-adoption of low-value clinical practices: a scoping review
BMC Med. 2015; 13: 255.

• A systematic review of the literature, current terminology and frameworks around de-adoption of low-value clinical practices identified 109 relevant studies.
• There were 43 unique terms referring to the process of de-adoption—the most frequently cited was “disinvest” (39 % of citations).
• Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. 
• Lists of low-value practices were provided by eight citations (table5)
• Eleven citations described 13 frameworks to guide the de-adoption process, from which the authors developed a model for facilitating de-adoption. (Fig4)

Metrics to support the case for prevention

Health economics metrics to support the case for prevention
Optimity Advisors for PHE, 22 July 2015

• A review of tools and evidence summaries to help local authorities and the NHS make the case for investment in prevention or early intervention, to prioritise investment (and disinvestment) or to improve the use of existing resources invested. 
• Other useful documents relating to prevention and early intervention tools here

AMRC launches Choosing Wisely programme

Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
BMJ 2015;350:h2308 (12 May 2015)

• The Academy of Medical Royal Colleges is launching a Choosing Wisely programme along the lines of the US initiative to get doctors to stop using interventions with no benefit.
• To ensure the development of a Choosing Wisely culture in clinical practice, the academy suggests:
• Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often be the best approach
• Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?”
• Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education
• Commissioners should consider a different payment incentive for doctors and hospitals.


• An American study published in BMJ has demonstrated only modest success so far. See BMJ 2015;351:h5437 (Available through NHS Open Athens)
• Follow "Choose Wisely" research on PubMed.

Decommissioning Evidence Review

Decommissioning Evidence Review
Midlands & Lancashire CSU Strategy Unit – Evidence Analysis Team, December 2014

• Evidence to support the decommissioning process and covers decommissioning activity within the NHS, priority setting, tools used to inform decommissioning activity such as the PBMA. 
• Includes case studies and examples of toolkits to support decommissioning.

Looking at disinvestment decisions

Saving money in the NHS: a qualitative investigation of disinvestment practices, and barriers to change.
The Lancet, Volume 382,supplement 3, Page S18, 29 November 2013.Meeting Abstract.

• Extracts:
• Using an ethnographic approach two NHS decision-making groups were followed up for 14 months through observations of routine meetings (n=8), and semistructured interviews with group members and front-line clinicians whose practice had been affected by disinvestment (n=28). 
• Meetings revealed few examples of active disinvestment decision making, with agendas dominated by requests for new health-care provision. Interviews revealed challenges in identifying opportunities for disinvestment, with previous approaches being unsystematic and unsustainable. A lack of capacity, methods, and training were key.
• Conclusion: Our findings support the urgent need for sustainable methods to guide local disinvestment practices.

Disinvestment - how is it being done across the NHS?

Tackling disinvestment in health care services
Williams, Iestyn;et al. Journal of Health, Organization and Management 2013 (in press)

• An exploration of the experiences of budget holders within the NHS in attempts to implement programmes of disinvestment, and to consider factors which influence the success (or otherwise) of this activity. 
• This paper begins with clarification of terminology and a summary of the current state of knowledge with regard to health service disinvestment, before presenting and discussing findings. 
• Interviews with 12 PCT staff identified five types of activity currently carried out within the English NHS that might be classified as ‘disinvestment’ie‘invest to save’, substitution, retraction, restriction and ‘true disinvestment’. 
• Overall, one of the key messages from the research is that effective disinvestment is reliant upon relationships at both a local and national level.

Personal health budgets - examination of the evidence and issues by Nuffield Trust

Personal health budgets: challenges for commissioners and policy-makers - Research summary
Nuffield Trust, 28 August 2013

• An examination of personal health budgets - at what they are, how they will work in practice, and the issues they raise. 
• Includes evidence from the national evaluation and an exploration of some of the issues that will be raised for commissioners and policy-makers as personal health budgets are rolled out.
• Key Points
• To date, the numbers of personal health budgets implemented in each local area has barely exceeded 100 people. Their extension to people in receipt of continuing care, and after that to those with long-term conditions, presents a much larger challenge for commissioners, who will need to reassure themselves that a wider range of providers demonstrate sufficient quality to merit inclusion.
• Clinical commissioning groups will also need to be ready to decommission services not chosen by budget holders; but at a pace that allows providers the chance to adapt and minimises the risk of market shrinkage (leaving individuals with fewer choices than before). Likewise, efforts aimed at diversifying the market of providers need to be carried out with care to avoid destabilising existing providers.
• For the system to work, new infrastructure around budget setting, care planning and system monitoring is required; funding for which would need to be found in existing budgets. There is some evidence to suggest that some efficiency can be achieved by ‘piggy-backing’ on the systems that already exist to support personal budgets in social care.
• Policy-makers need to be aware that there is a risk of a postcode lottery emerging, with much of the decision-making as to whether to offer personal health budgets, for whom and at what pace remaining in the hands of clinical commissioning groups. Not only will the value of a personal health budget be different in each area, but also the availability of personal health budgets for particular conditions is likely to vary.
• Bringing personal health budgets together with personal budgets in social care to create integrated individual budgets potentially offers a new route to service integration at the level of the user and carer. A ‘dual carriageway’ approach which brings together the referral, assessment, budget setting, planning and monitoring of different budgets without the complexities of structural integration between organisations and government departments may be helpful in this respect.

Creative decommissioning - an innovative model

The art of exit: In search of creative decommissioning
NESTA, April 2012

• This research report discusses decommissioning in the context of public services innovation and presents a new model for transformational public innovation
• The research is based on a quantitative survey of over 200 public leaders from local government and health organisations on current drivers and approaches to decommissioning and qualitative analysis of over 60 cases of decommissioning in public services

A Kings Fund guide to rationing

Thinking about rationing

Kings Fund, 3 May 2012

• A guide to the practicalities and controversies surrounding allocation and use of resources, what is known about rationing in practice. 
• Includes examples and illustrations, drawing on the available evidence and conversations with clinicians and managers

Disinvestment - read all about it

Disinvestment - A reading List Updated March 2012
QIPP Right Care

A tool to support prioritisation and disinvestment decisions

How to prioritise disinvestment in support services
HSJ 7 Feb 2012

• NHS National Services Scotland has developed a tool to ensure decisions about prioritisation and disinvestment can be made systematically and objectively, relying on the best available information and evidence, applied in a practical and pragmatic way.