Sarah Markham describes a new programme that aims to improve the quality of patient care by reducing ineffective treatments
Research shows that some medical interventions are not clinically effective or are only effective when they are performed in specific circumstances. As medical science advances, some interventions are superseded by those that are less invasive or more effective. At both national and local levels, there is a general consensus that the NHS could get better at ensuring that the least effective interventions are not routinely performed, or that they’re only performed in more clearly defined circumstances.
In 2017 NHS England and NHS Clinical Commissioners launched a new programme focusing on medicines and products that should not be routinely prescribed in primary care (either because they are relatively ineffective or in some cases potentially harmful, or because there are other more effective, safer, and cheaper alternatives). The Evidence-Based Interventions (EBI) programme is the counterpart to that programme. It is being complemented by new national ambitions to embed personalised care across England, so that shared decision making between patients and clinicians becomes the norm.
The aim of the EBI Programme is to improve the quality of patient care and treatment by reducing ineffective treatments and unwarranted variation across England. Any resulting cost savings will be reinvested back into the health service. This isn’t about taking money out of the NHS, it’s about making better use of it. Reducing avoidable harm to patients, and helping clinicians to maintain their professional practice in line with the changing evidence base, will also create space for innovation and avoid waste for patients and taxpayers.
As part of this programme a national steering group has been established, which includes two patient representatives (one being myself). The purpose of the steering group is to be a critical friend, not to make decisions. For instance, the steering group noted that of the 17 interventions initially included in the programme, three are specifically related to women. We therefore advised the board that they should include relevant women specific groups in their consultation engagement.
The programme has developed via a collaborative process and is fully supported by its four partners: NHS Clinical Commissioners (NHSCC), the Academy of Medical Royal Colleges (AoMRC), NHS Improvement (NHSI), and the National Institute for Health and Care Excellence (NICE).
Over a period of three months, beginning at the launch of the programme in July 2018, a consultation was held to look at the design principles, the interventions which should be targeted initially, proposed clinical criteria, which activity goals should be set, and delivery actions, including proposed new terms in the NHS Standard Contract. The main themes to emerge from the consultation included public and patient worries about poor and reductive coverage of the EBI programme in the national media, and possible limitations on clinical decision making and patient choice.
Commissioners, providers, and other professional bodies alike offered their support, with many stating that these proposals reflected existing processes at the local level. Commissioners and providers also had queries about aligning the programme with NICE guidance and the availability of alternative treatment options. As a consequence of this feedback, relevant detail has been added to the EBI clinical criteria, and NICE guidance around patient choice have been carefully adhered to.
A question which I have asked is whether there is anything within the guidance and the wider programme that might stifle clinical innovation. The answer is that in no way does the EBI programme want to stifle innovation. Within the guidance (to be published later this month) there will be clear direction to clinicians and academics to continue to pursue NIHR and other funded medical research projects in the areas covered by the programme.
Previous attempts to decommission interventions on the basis of clinical evidence have sadly faltered through the lack of sustained national and local drive and the absence of formalised levers to support implementation. To prevent this, the EBI programme will be introducing new levers and a range of measures to monitor and support progress. Local system audits (commissioner and provider) will review compliance and CQC inspections will align with the policy. Good practice will be identified and disseminated.
Another very positive feature is that it has already been decided that shared decision making (SDM) will be a key mechanism to support the implementation of the programme at the individual doctor and patient level. To this end, the EBI programme is working closely with Alf Collins who is the national policy adviser in person centred care at NHS England.
The EBI programme is also aligned with the successful NHS Scotland realistic medicine initiative, which was championed by Scotland’s chief medical officer, Catherine Calderwood. The project, which started in 2016, aims to reduce overmedicalisation and to avoid unnecessary treatment (by encouraging doctors to question their practice and listen more to what their patients want for themselves). According to Calderwood, many doctors have already expressed their support for this shift. “Lots of people have told me they have been practising medicine in this way for years, but now they have been given permission to admit it.”
There is a related English programme, headed by the Rethinking Medicine Working Group, that intends to convert the Scottish social movement of realistic medicine into action through what we call the NHS Comprehensive Model of Personalised Care. This is focused on achieving full implementation of shared decision making, patient activation, personalised care and support planning, social prescribing, patient choice, and personal budgets. According to Ian Dodge, national director, strategy and innovation, at NHS England, all of this is “about focusing on ‘what matters to patients’ rather than ‘what’s the matter with them’ (a lovely phrase first developed in Norway).”
I really hope that the EBI programme succeeds in achieving its aim of reducing use of ineffective treatments and thereby improving the quality of care and treatment experienced by patients. I am aware from attending meetings just how hard everyone involved in the programme is working to make it a success, and of the high degree of careful thought that has gone into its design and implementation planning. Ultimately, the fate of the programme lies in the hands of clinicians, service managers, and patients, who I hope will do their best to understand and support this very grounded and purposeful programme.
Sarah Markham is an academic mathematician and patient representative currently pursuing a second PhD in theoretical computer science. She is a member of the BMJ Patient Advisory Panel. Twitter: @DrSMarkham
Competing interests: None declared.