Delivering a national de-adoption programme: a documentary analysis of local commissioning policy compliance with England's Evidence-based Interventions programme (EBI)

Background: In 2019 the English National Health Service (NHS) launched a national de-adoption programme to stop or limit access to surgical procedures considered to have little, or uncertain, evidence of benefit to justify their risks and/or costs: the Evidence-Based Interventions (EBI) programme. Central to the programme was the publication of guidance detailing clinical recommendations targeting 17 surgical procedures: four to be stopped and 13 to be restricted to patients satisfying specific criteria. Local commissioning organisations, NHS bodies responsible for purchasing surgical services, were instructed to reflect national EBI recommendations in their local commissioning policies. This study (which is part of the NIHR OLIVIA study, an evaluation of the EBI programme) assessed local commissioning policy compliance with EBI recommendations and identified funding mechanisms employed locally to promote enforcement. Methods: A documentary analysis was conducted on a purposive sample of local commissioning policies for each of the 17 EBI surgical procedures. Local policies were compared to EBI recommendations and any differences were categorised against an established five category framework for capturing differences in local policies. Funding mechanisms were also recorded. Data were analysed using descriptive statistics supported by written summaries to describe the nature of discrepancies between local and national recommendations. Results: Three hundred six local commissioning policies were analysed. 72% (44/61) of procedures to be stopped and 43% (106/245) of restricted access policies matched EBI recommendations. Concordance rates varied by surgical procedures. Where local policies for the 13 restricted access procedures differed, variations were most commonly categorised as differences in diagnostic approach followed by differences in specification of symptom severity and disease progression. The funding mechanism most frequently stated for the stopped procedures was ‘Individual Funding Request’ (74%, 45/61), whilst for restricted access procedures, policies relied on ‘Criteria Based Access’ (48%, 117/245) followed by ‘Prior Approval’ (33%, 80/245). Conclusion: This study, to our knowledge, is the first to explore variation between local and national de-adoption policies. With under half of local commissioning policies matching national EBI recommendations, reliance on the take up of national de-adoption policy is inadequate. More support is needed for local commissioners to reflect national guidance.