Workshop to share experience and thoughts and to promote discussion on use of evidence in decision-making in NHS Commissioning (England)

1. THE GOOD, THE BAD
AND THE EVIDENCE
Siân Jones, Head of Evidence & Effectiveness,
Avon Primary Care Research Collaborative
Alison Turner, Head of Evidence Analysis,
Midlands & Lancashire Commissioning Support Unit
@EvidentlySian @ali_pals

2. @EvidentlySian @ali_pals
Today’s session – what’s the story?
• NHS commissioning – an introduction
• What do we mean by ‘evidence’ in commissioning
• How decisions are made
• Why it isn’t easy – the challenges
• Discussion - real life example
• Renewed impetus for evidence informed commissioning –
what next?

3. @EvidentlySian @ali_pals
Who are we?

4. @EvidentlySian @ali_pals
Commissioning – the what
• A complex process of procuring health services
through
• assessment of population health need
• planning of services
• purchasing services (limited budget) from providers
• monitoring
• Ongoing activity
• Diversity and complexity of services

5. @EvidentlySian @ali_pals
Commissioning is about…
• Doing the right things
• Making the right choices and investment
decisions and getting the best balance of
services
• Doing things right
Getting the best value for money and
achieving the desired outcomes
Beecham J, 2006 Beyond boundaries, citizen-centred local
services for Wales, Cardiff: Welsh Assembly Government

6. @EvidentlySian @ali_pals
Commissioning – the who
• Clinical Commissioning Groups (CCGs)
• Clinically led statutory bodies
• Health & Social Care Act 2012
• 209 CCGs across England
• 2/3 NHS England budget: £71.9bn 2016/17
• Commissioning Support Units (CSUs)
• finance, HR, contracting, data etc
• Public Health (Local Authority)
• NHS England – primary care; specialised services

7. http://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england

8. @EvidentlySian @ali_pals
Example questions in commissioning
of services
• Which models of service delivery are the most appropriate?
• How should changes to services be implemented?
• What impact do new models of care have on relationships
between users and professionals?
• How can different health care professionals work in teams to
provide more integrated care to users?

9. @EvidentlySian @ali_pals
Evidence based medicine
“The integration of best research evidence with clinical
expertise and patient’s values.”
Sackett DL et al; Churchill
Livingstone,2000
EBM

10. Evidence informed commissioning
Strategic decision making – populations
Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s Encyclopedia of
Psychology, 4th edition (pp. 603-607). New York:Wiley
Population
needs/
demands
Finite
resources

11. @EvidentlySian @ali_pals
Evidence and value based healthcare
Population
needs/
demands
Finite
resources
VALUE
• that patient gains from own care
• that whole population gains from investment in their healthcare
IMPROVE PRODUCTIVITY
• all work differently & smarter
• reshape services
Better value for every £ spent
To achieve more for less
To create more value for patients
Need the best
available evidence

12. @EvidentlySian @ali_pals
The danger is…
‘There’s lots of commissioning work going on, but
we don’t have much evidence about what works,
not much analysis, and little real change in
services.’
• Ineffective commissioning which is:
• Not evidence–based
• Has very little impact on service configuration
• Does not engage stakeholders
• Does not meet the future needs of the population

13. @EvidentlySian @ali_pals
‘Journey of evidence into commissioning’
Mobilising Knowledge
• Use of evidence is NOT simple
• Not a linear process: from supply demand
Much more complex…
• Healthcare commissioning ‘most challenging context for use of
evidence and best practice’ (Checkland et al 2011)
• Evidence is not ignored – incorporated into practice via ‘mindlines’
(Gabbay & Le May 2004)
Checkland http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1808-240_V01.pdf
Gabbay & le May http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524553/

14. @EvidentlySian @ali_pals
What is “evidence” in this context?
Expertise
Evidence
from local
context
Critically
evaluated
research
Perspectives
of those
impacted
Decision
Experiential
Theoretical
Empirical
Adapted from: Briner, R. B., et al. (2009) Evidence-Based
Management: Concept Cleanup Time? Academy of Management
Perspectives, 19-32.
Adapted from Williams, I. and Glasby, J. (2010) Making ‘what
works’ work: The use of knowledge in UK health and social
care decision-making. Policy and Society, 29, 95-102.

15. @EvidentlySian @ali_pals
Why is evidence important?
• Austerity in the NHS
• Increasing demand
• Increasing financial pressures
• “Wicked problems”
• Expectations
• 5 Year Forward View
• Scale and pace of change
• Pressure to be innovative
• A complex environment
• Complexity, volatility, uncertainty, ambiguity‡
• “Zone of productive distress”‡
• Tensions and trade-offs
‡Ghate, D., et al. (2013) Systems leadership: exceptional
leadership for exceptional times: synthesis paper. The Virtual
Staff College.

16. @EvidentlySian @ali_pals
Variable use of evidence
Overuse Underuse Misuse/ variation
Over use of health
service interventions
where they are not
particularly effective
Health service
interventions known to
be effective but are not
applied appropriately
Use of health service
interventions for which
the evidence base is
unclear or leads to wide
variation
Measurement of patient
satisfaction using poorly
conceptualised
instruments
Lifestyle and
behavioural
interventions to improve
health
Shifting services to out
of hospital settings to
save money
Adapted from Walshe, K. and Rundall, T. G. (2001) Evidence-based Management: From Theory to
Practice in Health Care. Milbank Quarterly, 79, 429-457

17. @EvidentlySian @ali_pals
Exercise: scenarios
Pick one of the scenarios and list the types of evidence
which might be needed in each case:
• What types of evidence might offer useful insights?
• Where would you find these types of evidence?
• Are there types of evidence which may not be appropriate
for this scenario?

18. @EvidentlySian @ali_pals
The reality: making decisions
• Decisions made by groups rather than
individuals
• A need to integrate multiple sources and
types of evidence, to consider evidence
“in its totality"
• “Variance in value”‡ with preferences
towards practice-based and patient-
generated evidence
• Context is important to help understand
how evidence may apply locally
“People can’t argue with concrete evidence
about what actually someone has
experienced”
Bjorn Larsson, CC BY-SA 3.0
https://commons.wikimedia.org/wiki/File:Jigsaw_puzzle_01_by_Scouten.j
pg
‡ Weber, E. P. and Khademian, A.M. (2008) Wicked Problems,
Knowledge Challenges, and Collaborative Capacity Builders in Network
Settings. Public Administration Review, March/April, 334-349.

19. @EvidentlySian @ali_pals
The reality : making decisions
• Evidence typically used to build case for change, inform design of
solutions, build consensus, challenge assumptions
• Whilst evidence is used to support design of change, little to suggest this
is sustained through lifecycle of the programme
• Knowledge mobilisation important to “fail fast, learn fast”
• Time pressures often result in a “satisficing” strategy (stopping when they
feel the information is “good enough“)
Highways Agency CC BY 2.0
https://en.wikipedia.org/wiki/Gravelly
_Hill_Interchange

20. @EvidentlySian @ali_pals
Evidence and complexity
• Complexity science
increasingly informing large
scale change:
• Advocates small scale pilots and
experiments with “minimal
specifications”
• Iterative Plan Do Study Act cycles
• What does this mean for how
we work as evidence producers
and knowledge brokers?

21. @EvidentlySian @ali_pals
Barriers to using evidence
• Evidence:
• hard to use
• gaps and uncertainties
• relevance
• timeliness
• Individual
• skills
• confidence
• Organisational
• capacity
• culture
• Wider system
• fragmented support
Phil Roeder, CC BY 2.0
https://commons.wikimedia.org/wiki/File:Hurdles_(Scenes_fro
m_a_Track_Meet).jpg

22. @EvidentlySian @ali_pals
Enablers?
• Helping decision makers to apply evidence locally by being more
explicit about the context of research and evaluation studies
• Balancing rigour and timeliness by identifying which questions
warrant rapid review or in-depth research
• Embedding evidence and knowledge mobilisation throughout the
lifecycle of commissioning/transformation
• Researchers and practitioners working together to prioritise research
questions using methods which support iterative change
• More collaboration in evidence support to reduce duplication

23. @EvidentlySian @ali_pals
Case study
• Business case – CCG planning round 2015/16
• Priority programme area: diabetes
• Long Term Conditions Steering Group
• Business case template – includes reference to evidence
• 12 month trial

24. @EvidentlySian @ali_pals
Exercise: business case
1. What surprises you?
2. What sources of evidence have been used to support
the business case?
3. What is your view of the ‘case for change’ section?
4. Has a clear issue/question been identified that the
evidence will support?
5. Do you feel confident that this service model provides
an effective solution to the issue/question?

25. @EvidentlySian @ali_pals
Feedback from group work
• What could change or be done better?

26. @EvidentlySian @ali_pals
Local observations – business cases
Variable
quality
Reliance on
‘data’
Last minute
Need timely
expert input
Targeted on
solution
What is the
problem?
Little
challenge at
senior level

27. @EvidentlySian @ali_pals
It’s all happening!
• Renewed emphasis on research and evidence!
• NHS R&D Forum
• Primary care workstream – guide for commissioners
• NHS England R&D – Research & Innovation
• Insight tool
• Infographic (research landscape)
• E-repository
• Community of practice
• Alliance for Useful Evidence and partners
• The Commissioning Elf – National Elf Service

28. @EvidentlySian @ali_pals
Next steps
• Manifesto for evidence informed commissioning
• What Works Global Summit
• Alliance for Useful Evidence
• Evidently Commissioning blog
• Network
• Connect with us……
Sian.Jones@bristolccg.nhs.ukalison.turner14@nhs.net

29. https://evidentlycommissioning.wordpress.com/