Investigating treatment-decision making in the context of de-implementation

The National Institute for Health Research Collaboration for Leadership in Applied Health and Research Care West (NIHR CLAHRC West) at the University Bristol is inviting applications for a fully-funded PhD studentship to commence in October 2019.

Location - NIHR CLAHRC West, Level 9, Whitefriars, Lewins Mead, Bristol BS1 2NT
AND Population Health Sciences, Canynge Hall, University of Bristol
Hours - Full time
Contract (temp/perm) - Contract/temporary

Background
The national health service (NHS) is under constant pressure to improve health outcomes, but needs to take account of constrained budgets and growing demand. Many treatments and investigations (‘technologies’) currently used in the NHS were adopted before evidence-based standards were introduced. Technologies can also become obsolete or may be used beyond their originally intended scope. ‘De-implementation’ is the process of stopping or restricting health technologies that are harmful, ineffective, or not cost-effective - either as a whole, or in certain patient groups. NHS England has put forwards a list of technologies for de-implementation, but experience from several high-income countries- including the UK- show that attempts to stop or curtail embedded practice often culminates in little change. Further research is needed to understand how de-implementation is operationalised by commissioners and front-line practitioners in local settings. It is already known that commissioners adopt local policies stipulating criteria for referral/treatment, but these policies can vary from one Clinical Commissioning Group to another. There has been little empirical research around how these policies are formulated and deployed in practice. Treatment-provision is also likely to be informed by discussions between practitioners and patients: shared-decision making is thought to be associated with patients choosing less intervention, but this has not been examined in the context of de-implementation.

The proposed research will investigate local delivery of national de-implementation directives, with a focus on how this influences treatment decision-making. Case studies of technologies put forwards for de-implementation will be selected, to include an example where there is evidence indicating lack of (cost) effectiveness (e.g. from high-quality RCTs or meta-analyses), and another where the evidence-base is less clear. Hospital Episode Statistics data and the National Clinical Procedures Benchmarking tool will be used to identify high/low utilisation regions for each procedure.

Qualitative ethnographic approaches will then be used to investigate the contextual and communication-related factors that influence treatment provision including: i) interviews and document analysis to map out the treatment/referral pathways, ii) interviews to explore health care professionals’/ commissioners’ interpretations of evidence and perspectives on de-implementation, iii) observations/audio-recordings of communication during doctor-patient encounters, and iv) interviews with patients to examine their interpretations of information and persisting information needs. Findings from the case studies will be used to support commissioners and practitioners provide optimal care in the face of future de-implementation initiatives. This may include recommendations to support local policy development, communication-related guidance for practitioners, or patient-facing tools to support balanced information-provision and shared-decision making.

We are looking to recruit an enthusiastic and talented PhD student to work on this project with Dr Leila Rooshenas, Professor Will Hollingworth, Professor Jenny Donovan and Dr Amanda Owen-Smith at the University of Bristol. This 3-year studentship will provide training in both quantitative and qualitative methods.

For further details please see our full advert on our Department of Population Health Science home page (https://www.bristol.ac.uk/medical-school/study/postgraduate/population-health-sciences/).

How to apply:
Please make an online application for this project at http://www.bris.ac.uk/pg-howtoapply. Please select Faculty of Health Sciences and Population Health PhD on the Programme Choice page. You will be prompted to enter details of the studentship in the Funding and Research Details sections of the form. For general enquiries linked to the online application process, please email [Email Address Removed]

Candidate requirements:
Academically, candidates for the PhD may qualify for admission if they have: a Master’s degree; an Honours degree, or a 4-year Bachelor’s degree, plus at least 1 year of registration for the Master’s degree; a 3-year Bachelor’s degree plus at least 2 years of registration for a Master’s degree. The PhD candidate will ideally have a background in health economics, applied health research or another relevant (social science or medical) discipline.

Contacts:
Interested and suitably qualified candidates should make informal contact with Dr Leila Rooshenas ([Email Address Removed]). The project is available for start date from 1st October 2019