1. www.strategyunit.co.uk
Evidence-based guides to
support co-commissioning
Alison Turner, Sharon Stevens and Shiona Aldridge
Strategy Unit, Midlands and Lancashire Commissioning Support Unit
Background and aims Results
Our approach Next steps
The West Midlands Clinical Senate commissioned the
Strategy Unit to create a resource to support local primary
care development strategies. The resource aims to
summarise available evidence on aspects of primary care
quality which impact on health, patient outcomes and
service utilisation in order to enable local health economies
to discuss and decide local priorities for development.
Primary care development is a priority area for local health
economies, driven by the shift towards co-commissioning
and the new care models proposed in the Five Year
Forward View. However, the evidence base on quality in
primary care is variable. Even where evidence is available,
the application of learning from research and evaluation
needs a deep understanding of local context. Local
strategy and planning will therefore need to be driven
by consensus built through engagement with stakeholders
and informed by evidence where available. This resource
is intended to provide a framework for commissioners and
providers to instigate conversations locally.
Our final report is being presented to the Clinical Senate in
March 2015 with a view to disseminating across the West
Midlands over the Spring period. Initial feedback suggests
the resource will provide a useful framework for local
discussions; for example, a local CCG plans to use this
resource to prompt conversations with patients regarding
what excellence in primary care looks like for them. The
CCG is planning to use the patient feedback to co-produce
Key Performance Indicators in the GP contract.
Our work to date will inform ongoing and future work. We
are working with several local CCGs on their primary care
development strategies and in particular, supporting the
next phase of the Future Fit programme, which is focused
on supporting primary care to manage the shift of care
closer to home.
The resource is organised from three perspectives: patient,
clinical and practice, reflecting themes which emerged from
the evidence review. The key messages have been
summarised in the form of graphics for each of the three
perspectives, to provide visual aids for commissioners
and providers to instigate local conversations. A set of
questions has also been included in the appendix which
may help to frame local discussions.
The main themes identified were:
The patient persepective
- Developing patient
centred culture
- Access for patients
- Continuity of care
- Empowering patients
- Information and technology
- Community engagement
The clinical perspective
- Ways of working
- Dignosis and referrals
- Prescribing Urgent care
- Population management
- End of life care
The practice perspective
- Collaboration
and partnerships
- Workforce
- Continuous Improvement
- Leadership
- Change and transformation
- Physical environment
Our methodology included the following stages:
The review included a search of Medline, Embase, HMIC,
Cochrane Library and sources of grey literature. The final
report included a summary of evidence supported with
published case studies where available.
Scope
the work
Conduct
the search
Filter search
results
Present
draft review
Write a
narrative
Summarise
and appraise
papers
Test key
findings
Present
final review Dissemination

2. Transforming commissioning
with evidence
Alison Turner, Shiona Aldridge and Sharon Stevens
Strategy Unit, Midlands and Lancashire Commissioning Support Unit
Introduction Methods
Commissioners in the NHS face the challenge of
identifying high-value interventions and initiatives which
offer a significant return on investment (improved outcomes
and reduced burden on health services) in a climate of
significant financial pressures. The Five Year Forward View
sets out significant change through new care models. There
is a clear need to learn from interventions and initiatives
which have successfully improved outcomes for patients.
Before investing in new initiatives, it is prudent to begin with
a review of the evidence base to understand what works,
in what context, and why – also, how interventions can be
adapted and implemented locally. This can help avoid the
risk of investing in initiatives which offer only marginal
benefits or possible harm. However, research* has shown
that commissioners vary greatly in their use of evidence in
decision making.
*Clarke A et al (2013) Evidence-based commissioning in the English NHS: who uses which
sources of evidence? A survey 2010/2011, BMJ Open, 3, e002714. Doi: 10.1136/bmjop-
en-2013-002714.
Understand
requirements
Supplement
with data
collection
Write a
narrative
Scope the
work
Appraise and
summarise
papers
Test key
findings
Conduct
the search
Filter search
results
Present
findings
Results
Our evidence reviews have contributed to large scale
change in a number of ways, informing:
- the clinical design of a system reconfiguration;
- a redesign of intermediate care;
- a redesign of respiratory services, leading to wider
availability of pulmonary rehabilitation;
- the specification of a community diabetes service;
- the evaluation of a virtual ward pilot;
- the evaluation of an integrated care service;
- decommissioning and disinvestment of services.
Our key challenge is in balancing timeliness alongside
rigour and quality. We often find the evidence base is
underdeveloped, highlighting the need for rigorous
evaluation of commissioning interventions, thus building
a stronger evidence base.
Conclusions
Commissioners are generalists, often responsible for a
number of different service areas. They need tailored
evidence products, offering high level, “ready to use”
guides and tools. The volume of the knowledge base for
commissioning can be significant but the quality is variable
and for some key initiatives, the evidence base remains
underdeveloped, risking high cost and low
value investments
Methods
We start change programmes with a review of the relevant
evidence base. As much of our work tends to be to tight
deadlines, we have developed a pragmatic process for
producing evidence reviews, which aims to achieve the
optimum balance of rigour and timeliness. Our process
follows 9 steps.
Aims
The Strategy Unit exists to help clients improve health and
care. We combine advanced, yet practically grounded,
skills and expertise in analysis, evidence review, strategic
financial planning, policy and strategy development,
consensus building, programme design and implementation
and trusted advisor support for senior leaders.
Specifically, we produce bespoke, detailed syntheses of
the published evidence base on clinical/service topics and
a series of ‘methods reviews’, on mechanisms and
methodologies of potential application in achieving
service change.
www.strategyunit.co.uk