Reducing hospital admissions: A Realist Evaluation of Welsh Ambulance Service’s gatekeeping strategy

Abstract

Abstract

This thesis is a novel, theory driven evaluation of Welsh Ambulance Services NHS Trust (WAST) gatekeeping stratagem, from the paramedic standpoint.


Study aim and objectives

The study aimed to develop, test, refine and correlate 'admission avoidance' programme theories with extant theory, to explicate drivers and barriers to strategic policy implementation; what works (or not), for whom, in what circumstances. The objective was to conceptualise paramedic activities and their integration with existing contingent systems, by extrapolating context, mechanism, and outcome (CMO) configurations to illuminate inter-relationships and dependencies - mapping realities of the prevailing culture, and textual organisation of paramedic activity, to inform realist programme theory and evaluation of comparable programmes across healthcare specialities.


Methods

Pertinent social programmes were framed according to organisationally endorsed quality and prudent standards and deciphered with modes of inquiry commensurate with realist evaluation principles, to understand intended intervention outcome patterns and underlying causal mechanisms according to contexts of paramedic practice. Coterminous with iterative and evolving realist reviews of the literature, a soft systems methodology (SSM) stakeholder group (n=3) contributed to initial, tentative theoretical mapping that culminated in idealised root definitions for each intervention and conceptual models considered necessary for their implementation. A realist lens then guided theoretical augmentation of SSM modelling, according to context (C), mechanism (M), and outcome (O) configurations that consolidated conceptual CMO relationships and inter-dependencies. Institutional ethnography concluded theoretical testing - comparing SSM models with non-participant observations (n=12) of everyday paramedic work and descriptive questions of each social situation - highlighting the juxtaposition between ruling organisational texts and tensions resulting from their execution as extrapolated from paramedic experiential knowledge. Middle-range theory then equated and amalgamated multiple iterations of enquiry, aligning applicable constructs and conceptual commonalities with studied phenomena of interest.







Findings

Three SSM root definitions and conceptual models structured initial analysis of prevailing problematic social situations, according to theory areas that aligned with the worldviews of participating paramedics. The culmination of six conjectured CMO hypotheses then crystallised paramedic admission avoidance paradigms according to three social systems: Gatekeeping system; Needs-based system; and Safety-netting system. Explicit explanations for the cross-pollination of countervailing social programmes, corresponding causal mechanisms and intended social changes were further refined with empirical evidence, and programme rigour elicited from their extrapolation with opposing contextual social conditions, including: role assimilation; role dissonance; growth opportunity; permissive environment; volitionality; and controlling environment. Findings were synthesised and aligned with self-determination theory, as overarching explanatory schema, with particular emphasis bestowed to paramedic relatedness, autonomy, and competence for organisational attainment of contemporary strategic ambitions.


Conclusion

Identifying and examining tensions permeating everyday work through organisational texts, this study highlights the socio-contextual factors that undermine or support paramedic engagement, and development of the admission avoidance space according to their psychological need for autonomy, relatedness, and competence. Whilst theoretical propositions, derived from realist evaluation, remain within a constant flux and are therefore temporary, this study supports the perpetual architecture of organisational change by exposing latent and active mechanisms, with causal powers sufficient to trigger the intrinsic motivation to amotivation spectra. Specifically, paramedic engagement and compliance (or not) with admission avoidance initiatives is now better understood having teased out what does and doesn't work, for whom, and in what circumstances.

Date of Award	22 May 2025
Original language	English
Awarding Institution	Bangor University
Sponsors	RCBC Wales
Supervisor	Sion Williams (Supervisor) & Zoe Hoare (Supervisor)