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

Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis.
Health Services and Delivery Research  February 2021;9(2)

• A realist synthesis of evidence around “what works” in de-implementation of services. 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. 
•  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.

De-implementing wisely: developing the evidence base to reduce low-value care

De-implementing wisely: developing the evidence base to reduce low-value care
BMJ Quality & Safety 2020;29:409-417, 20 April 2020

• This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation. 
• Based on a worked example of applying CWDIF [in Canada] the paper presents a stepwise theory-based framework for de-implementing low-value care identified through Choose Wisely recommendations for reducing low-value care.

De-implementing wisely: developing the evidence base to reduce low-value care

De-implementing wisely: developing the evidence base to reduce low-value care
BMJ Quality & Safety 06 February 2020. doi: 10.1136/bmjqs-2019-010060

• This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.

Examining the impact of policy changes in access to state-funded provisions of gluten-free foods in England

Breaking bread: examining the impact of policy changes in access to state-funded provisions of gluten-free foods in England
BMC Medicine 201816:119, 2 August 2018

• Analysis of the impact of potential policy changes on different stakeholders (patient groups and CCGs), by exploring changes in expenditure on gluten free (GF) products across all CCGs in England between 2012 and 2017; understanding the groups of patients likely to be affected most by reduced prescribing of GF products; and cost-savings made by CCGs which have switched to a ‘complete ban’ with CCGs that have continued to provide GF prescriptions. 
• See : Gluten-free foods on NHS prescription - DHSC consultation closes 1 October 2018

Abstract

CCG 360° Stakeholder Survey National report 2017/18

CCG 360° Stakeholder Survey National report 2017/18
NHS England 12 July 2018

• This report provides an overview of findings of the CCG 360° stakeholder survey across all 207 CCGs. It highlights areas where CCGs are performing well and also outlines potential areas for improvement.
• A Case study annex 2017/18 includes case studies of high performing and improved CCGs -
• East and North Hertfordshire CCG: Building on a strong internal foundation by strengthening external relationships
• Greater Huddersfield CCG: Tailoring engagement to stakeholders’ needs
• Merton CCG: Working with stakeholders to improve services for patients and the public
• Surrey Heath CCG: Putting patients and the public at the heart of commissioning services
• Salford CCG: Engaging with stakeholders and working collaboratively to deliver a shared vision

NHS England Board meeting 4 July 2018 Highlights

NHS England Board meeting 4 July 2018

Agenda

• 1. Minutes of the Previous Meeting 
• 2. Chairman’s report 
• 3. Chief Executive’s Report 
• 4. Developing the NHS long term plan: reducing ineffective or wasteful clinical procedures 
• 5. Developing the NHS long term plan: primary care reform 
• 6. General Practice Services – programme update 
• 7. Second progress report from the Empowering People and Communities Taskforce 
• 8. NHS Performance and progress on implementation of next steps 
• 9. NHS Finance Report 
• 10. Reports from Board Committees 
• i. Commissioning Committee 
• ii. Investment Committee 
• iii. Specialised Services Commissioning Committee 
• iv Audit and Risk Assurance Committee 
• 12. AOB 

Highlights for CCGs and Arden GEM CSU below relating to 
4. Developing the NHS long term plan: evidence based interventions that should not be routinely commissioned.
5. Developing the NHS long term plan: primary care reform - GP contract reform including

• A review of the Quality and Outcomes Framework (QOF)
• GP payments in light of the growth of digital-first primary care

6. GP Services Programme Update
7. Second progress report from the Empowering People and Communities Taskforce

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. 

Planning, assuring and delivering Service Change for Patients

Planning, assuring and delivering Service Change for Patients
NHS England updated 22 March 2018

• A good practice guide for commissioners on the NHS England assurance process for major service changes and reconfiguration (including decommissioning).
• It sets out how new proposals for change are tested through independent review and assurance by NHS England, taking into account the framework of Procurement, Patient Choice and Competition Regulations. 
• CCGs are under a statutory duty to have regard to this guidance.

Protocol for when a service closes at short notice

Joint Working Protocol: When a hospital, services or facility closes at short notice
NHS England 1 February 2018

• Guidance to organisations when a hospital, service or facility closes unavoidably at short notice.
• The memorandum gives clear guidance and direction to any organisation involved in a short notice closure to take appropriate and timely action in supporting patients and making sure they get the care and treatment they deserve.

Decommissioning health care: identifying best practice

Decommissioning health care: identifying best practice through primary and secondary research a prospective mixed-methods study
Health Services and Delivery Research 2017;5(22) https://dx.doi.org/10.3310/hsdr05220

• This study examines the evidence base on which to guide policy and practice in decommissioning through expert opinion, a survey and interviews with CCGs and discussions with patient/service users. 
• The study concludes that 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. 
• Case studies include
• Decommissioning as part of the national reorganisation of paediatric burn care services in England
• Local decommissioning of an end-of-life home support service
• Decommissioning in the work of an Area Prescribing Committee
• Reorganisation of local primary and acute care services, involving decommissioning of a local hospital and centralisation of acute services at alternative sites
• 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.
• Definition: Decommissioning – defined as the planned process of removing, reducing or replacing health-care services.

Making difficult decisions

Making difficult decisions: Commissioning healthcare in changing times
NHS Clinical Commissioners, University of Birmingham 28 September 2016

• This report sets out factors that can enable CCGs to successfully command the confidence of the public, patients, local politicians and other key stakeholders when making changes.
• It contains top tips drawn from academic research and additional insight from those interviewed during the report, including commissioners, patient groups and NHS England. These are:
• Identify opportunities for improvement and safe and cost-effective change in service provision.
• Plan the change management process in advance.
• Base decision-making on robust data where available.
• Manage stakeholder perceptions through active engagement, consultation and nurturing trustworthy relationships.
• Recognise that local community, clinician and political support is vital, and engage these interests early.
• Develop an integrated communication and engagement strategy from the start

Lessons learnt from a hospital closure

Transfer of Services between Leeds York Partnership FT and Tees, Esk and Wear Valleys NHS FT: Reflections, Learning and Assurance Report
NHS England 31 March 2016

• This report outlines lessons learnt following transfer transfer of mental health services from a building which was found not to be fit for purpose to a new provider. 
• Recommendations fell under 3 headings: 
• Managing safe services in an unsuitable environment 
• The safe transfer of services between organisations (the commissioner would normally be the lead body nominated at the outset to take charge of the process of closure.)
• the process of varying the registration of the outgoing and incoming trust with the Care Quality Commission where services are transferring
• The report outlines lessons learnt by the organisations involved including the commissioning CCG, NHS Property Services and the FT.
• Recommendations in the report include "that NHS England take the lead in developing a memorandum of understanding for the sudden closure of hospital facilities on the grounds of serious quality or safety concerns."

Using variation to identify opportunities for disinvestment

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study.
Health Serv Deliv Res 2015;3(13)

• There is large inter-PCT variability in procedure rates for common NHS procedures. Variation is highest where the diffusion or discontinuance is rapidly evolving and where substitute procedures were available, suggesting that variation may be a proxy for clinical uncertainty about appropriate use. 
• Using data from two PCTs the researches examined opportunities and barriers for disinvestment. 
• Evidence to support commissioning decisions was limited. 
• Commissioning meetings were dominated by new funding requests and benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. 
• Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. 
• Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. 

Rationing in the NHS

Rationing in the NHS

Nuffield Trust 19 February 2015

• This pre-election briefing is intended to be a useful appraisal of current approaches to rationing.
• It includes an analysis of public attitudes to rationing and policy-setting; how rationing decisions are currently made and how much explicit rationing there is; how NICE and the Cancer Drugs Fund are working; and how much money rationing can save.

How are decommissioning decisions made?

Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services
Implementation Science 2014, 9:123

• Using a three round Delphi study of 30 international experts the research explores the factors and processes that shape the successful implementation of decommissioning decisions and consensus as to current best practice. 
• The research found a stark contrast between what experts thought should determine decommissioning decisions and what does so in practice mirroring technical and political aspects of decommissioning processes. 
• The best practice recommendations which we grouped into three categories—change management and implementation; evidence and information; and relationships and political dimensions.

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 commissioners textbook

Commissioning for health and well-being: an introduction
Edited by John Glasby, Policy Press 2012
ISBN: 9781847427922

Contents:

• Section 1: The commissioning cycle: New forms of strategic commissioning; Needs assessment; Decision-making and priority setting; Procurement and market management; Decommissioning;  Commissioning for service resilience;Commissioning for quality and outcomes
• Section 2: Key themes: The economics of commissioning; Public and user involvement in commissioning; The impact of joint commissioning; Commissioning in an era of personalisation
• Section 3: Conclusion and next steps