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Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care / Mark Kingston

Swansea University Author: Mark Kingston

  • E-Thesis – open access under embargo until: 14th May 2026

DOI (Published version): 10.23889/SUthesis.66480

Abstract

Despite an uncertain evidence base, emergency admission risk stratification tools have been widely promoted in the NHS. These tools are underpinned by algorithmic models using routine health data to calculate one year admission risk for all patients in a health community (typically a general practic...

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Published: Swansea, Wales, UK 2024
Institution: Swansea University
Degree level: Doctoral
Degree name: Ph.D
Supervisor: Snooks, Helen ; Porter, Alison ; Hutchings, Hayley
URI: https://cronfa.swan.ac.uk/Record/cronfa66480
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first_indexed 2024-05-20T14:26:22Z
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spelling v2 66480 2024-05-20 Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care 3442763d6ff0467963e0792d2b5404fa 0000-0003-2242-4210 Mark Kingston Mark Kingston true false 2024-05-20 MEDS Despite an uncertain evidence base, emergency admission risk stratification tools have been widely promoted in the NHS. These tools are underpinned by algorithmic models using routine health data to calculate one year admission risk for all patients in a health community (typically a general practice). The tools allow practitioners to identify at-risk individuals to target for preventative care, with the ambition to improve care, and reduce admissions/costs. This study explored why, how and to what extent emergency admission risk stratification tools were introduced in UK primary care, and stakeholder views. I undertook a multi-methods study incorporating systematic literature review; survey of 171 primary care commissioning organisations; follow-on interviews with a sample of commissioners (n=20); a user experience study of tool users (n=29) and a focus group with patients (n=9). The review found that although accuracy of the tools had been addressed, there was little underpinning evidence of effectiveness. Nonetheless, the survey confirmed largescale implementation across the UK; 86.5% of organisations had introduced a tool to general practice. Research evidence had little influence over decisions to implement, but the desire to align with policy recommendations was apparent. Interviews confirmed a complex landscape of tool introduction and use, but often as short-term pilots with few incorporating robust evaluation. I found that implementation challenges were prominent, including a lack of clarity over models of care for identified patients. Most tool users found them acceptable, were willing to use them (often on a trial basis) but reported usability and capacity issues. Patients saw opportunities for admission risk to be communicated in patient/clinician discussions, but I found no evidence that this approach was widespread.I conclude that the promotion and use of the tools was driven by optimism rather than evidence, and there remains a need to better integrate research, policy, and practice. E-Thesis Swansea, Wales, UK 14 5 2024 2024-05-14 10.23889/SUthesis.66480 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University Snooks, Helen ; Porter, Alison ; Hutchings, Hayley Doctoral Ph.D 2024-05-20T15:47:58.1686267 2024-05-20T15:21:05.5238926 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Health Data Science Mark Kingston 0000-0003-2242-4210 1 Under embargo Under embargo 2024-05-20T15:43:07.7452509 Output 8571686 application/pdf E-Thesis – open access true 2026-05-14T00:00:00.0000000 Copyright: The Author, Mark Rhys Kingston, 2024. Licensed under the terms of a Creative Commons Attribution-Non-Commercial-Share Alike (CC-BY-NC-SA) license. Third party content is excluded for use under the license terms. true eng https://creativecommons.org/licenses/by-nc-sa/4.0/deed.en
title Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
spellingShingle Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
Mark Kingston
title_short Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
title_full Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
title_fullStr Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
title_full_unstemmed Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
title_sort Policy implementation without evidence: a multi methods study of emergency admission risk stratification in primary care
author_id_str_mv 3442763d6ff0467963e0792d2b5404fa
author_id_fullname_str_mv 3442763d6ff0467963e0792d2b5404fa_***_Mark Kingston
author Mark Kingston
author2 Mark Kingston
format E-Thesis
publishDate 2024
institution Swansea University
doi_str_mv 10.23889/SUthesis.66480
college_str Faculty of Medicine, Health and Life Sciences
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hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Health Data Science{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Health Data Science
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description Despite an uncertain evidence base, emergency admission risk stratification tools have been widely promoted in the NHS. These tools are underpinned by algorithmic models using routine health data to calculate one year admission risk for all patients in a health community (typically a general practice). The tools allow practitioners to identify at-risk individuals to target for preventative care, with the ambition to improve care, and reduce admissions/costs. This study explored why, how and to what extent emergency admission risk stratification tools were introduced in UK primary care, and stakeholder views. I undertook a multi-methods study incorporating systematic literature review; survey of 171 primary care commissioning organisations; follow-on interviews with a sample of commissioners (n=20); a user experience study of tool users (n=29) and a focus group with patients (n=9). The review found that although accuracy of the tools had been addressed, there was little underpinning evidence of effectiveness. Nonetheless, the survey confirmed largescale implementation across the UK; 86.5% of organisations had introduced a tool to general practice. Research evidence had little influence over decisions to implement, but the desire to align with policy recommendations was apparent. Interviews confirmed a complex landscape of tool introduction and use, but often as short-term pilots with few incorporating robust evaluation. I found that implementation challenges were prominent, including a lack of clarity over models of care for identified patients. Most tool users found them acceptable, were willing to use them (often on a trial basis) but reported usability and capacity issues. Patients saw opportunities for admission risk to be communicated in patient/clinician discussions, but I found no evidence that this approach was widespread.I conclude that the promotion and use of the tools was driven by optimism rather than evidence, and there remains a need to better integrate research, policy, and practice.
published_date 2024-05-14T15:47:56Z
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score 11.036837

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