Motivations, mandates and accountability in demand management: A realist synthesis

Concern has been expressed about the number and appropriateness of GP referrals, in terms of whether they are necessary, whether they are properly directed and whether they include all the requisite information. Many interventions are in place attempting to reduce the overall rate of referrals and ensure patients are referred to the right person at the right time and in the right setting. These schemes, collectively termed Demand Management (DM), seek to provide checks and balances in the system administrative review of GP referrals, diverting referrals to other professionals, giving feedback to GPs and so on. Another ambition for these initiatives is to support the transfer of 'ownership' for cost containment activities down to individual clinicians. At the same time, patients are being offered increased choice of NHS and private service provision. NHS decision makers need a better understanding of the effectiveness of this family of programmes in order to guide their targeting and improve their implementation. Evaluating whether and how these interventions work has proved challenging, as has the task of bringing together this research to provide an overview of the strengths and weaknesses of the DM strategies. Such interventions are always implemented against a backdrop of other policy initiatives which may shape or even thwart DM planning. Given the considerable regional autonomy in the NHS, the schemes are strongly shaped by local conditions, making it difficult to know whether best practice in A will apply in B. Current ways of reviewing the literature are not always able take account of these implementation and contextual forces and sometimes focus ineffectively on the search for one-size-fits-all solutions. We propose to undertake a different sort of review, termed realist synthesis, to understand 'what DM initiatives work for whom in what circumstances and in what respects' in order to produce guidance for NHS decision makers to improve the implementation and targeting of DM interventions in local contexts. To do this, we will shift focus from intervention specifics to map out the dominant ideas, assumptions and challenges underlying how DM initiatives are supposed to work in practice. We will then review the evidence on the degree to which the outcomes produced by DM strategies, when implemented in different contexts, have matched the theories underlying them. We have identified four potential areas for review that will help to explain the varied fortunes of demand management initiatives. How can DM interventions: i) Respond to the different reasons for referral; ii) Manage the differences in knowledge, expertise and remit to practice involved in the substitution of clinical expertise; iii) Modify lines of accountability in relation to ownership of 'cost containment' ambitions; iv) Regulate provision at the same times as providing patients with increased choice of provision. We will then engage in reviewing evidence from different policy sectors and countries. We will search the literature to identify evidence about the assumptions behind DM strategies and then extract relevant data and review its quality. We will synthesise the data, exploring how different programmes have coped and failed to cope with these challenges and collect together the emerging lessons. These will provide the research backdrop for guidance for NHS decision makers to address the real life challenges they face in implementing and targeting of such schemes in local contexts. Our project will be a success if our guidance is found to assist NHS decision makers in choosing the balance and form of DM initiatives appropriate to their local practice culture, patient needs and the press of other demands on services.

https://fundingawards.nihr.ac.uk/award/11/1022/04

https://www.journalslibrary.nihr.ac.uk/hsdr/HSDR04020

 

Publications and outputs

Pawson R, Greenhalgh J, Brennan C and Glidewell E (2014) Do reviews of healthcare interventions teach us how to improve healthcare systems? Social Science and Medicine, 114: 129-137 https://doi.org/10.1016/j.socscimed.2014.05.032

Brennan C, Greenhalgh J, Pawson R. (2017) Guidance on guidelines: Understanding the evidence on the uptake of health care guidelines. Journal of Evaluation in Clinical Practice https://doi.org/10.1111/jep.12734