Evidence based commissioning - now and moving forward
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Presentation at Health Libraries Group conference, Scarborough September 2016, looking at the research behind evidence based commissioning - the evidence used, how it is found and how it is used - and a case study of a Commissioning Librarian.
![What is commissioning?
• Commissioning is the process of procuring health
services.
• It is a complex process, involving the assessment
and understanding of a population’s health needs,
the planning of services to meet those needs and
securing services on a limited budget, then
monitoring the services procured.
[Faculty of Medical Leadership and Management, 2012]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Evidence based commissioning - now and moving forward
- 1. Evidence based commissioning - now and moving forward Anne Gray, Knowledge Officer, Arden & GEM CSU HLG Conference September 2016
- 2. What is commissioning? • Commissioning is the process of procuring health services. • It is a complex process, involving the assessment and understanding of a population’s health needs, the planning of services to meet those needs and securing services on a limited budget, then monitoring the services procured. [Faculty of Medical Leadership and Management, 2012]
- 3. A “plurality” of sources [Swan 2012]
- 4. Analysis of items in 4 Knowledge@lerts July 2016 • 20 - “expert” groups (Kings Fund, Nuffield Trust, Health Foundation, NIHR) • 13 - NHS England/DH/PHE • 10 – clinical peer groups (Royal Colleges, Diabetes UK etc) • 6 – Guidelines/standards (NICE,CQC,NHS Improvement) • 5 – Local Government Association • 3 - case studies (CCG board papers, magazines) • 1 – peer reviewed journal
- 5. Looking for the evidence What the research says: • Commissioners look for themselves or rely on colleagues • Email discussion lists & alerts • NHS sources are constantly changing and confusing • Difficult to find commissioning/ management evidence • Don’t ask the library unless they have had previous contact • Library staff also found it difficult [Edwards 2013, Wye 2015]
- 6. [Wye et al. 2015, Wilson 2016] Using the evidence
- 7. A Commissioning Librarian • Service model to help my customer • Searching skills to identify the plurality of evidence • Report formats to meet the business need
- 8. Lessons learnt – Know your customer • What is business critical? • Understand national and local drivers • Speak the language • Tailored service Rather than merely searching for relevant articles, Anne reflected on the problem areas, searched for evidence of a range of successful interventions achieved elsewhere and provided a new measurable solutions for the CCG to adopt. This saved me time and added real value and a new angle of approach. CCG Director
- 9. Lessons learnt – Searching Health Serv Deliv Res
- 10. Lessons learnt – Synthesis&Summary • “Highlights …with an overview but also a link so I can go into more depth if interested • For busy people, as we all are, the snippets are great as you don’t have to wade through a whole load of words to understand what the info is about • Having everything in one email instead of having to remember where I saw this that and the other!!!” [Ass Dir CCG]
- 11. Resources to build on • Alerting services (CASH, Kings Fund) • Evidence Works Toolkit (Avon Primary Care Research Collaborative) • Commissioning Handbook for Librarians • Mailing lists • Embedded librarians / knowledge services
- 12. Skills to build on • Graduate Evidence Assistant pilot (Avon Primary Care Research Collaborative) • Knowledge for Healthcare – Synthesis techniques – Evidence for managers/commissioners training • Communities of practice across NHS knowledge staff
- 13. Moving forward • What can your library build on? • How can you work with other libraries? • What can you do next week?
- 14. Bibliography 1/2 • Faculty of Medical Leadership and Management, 2012 http://www.nhs.uk/NHSEngland/thenhs/about/Documents/Commissi oning-FINAL-2015.pdf • Epilepsy Commissioning Toolkit http://www.epilepsytoolkit.org.uk/ • Swann J et al Evidence in Management Decisions (EMD) NIHR Health Services and Delivery Research programme; 2012. http://www2.warwick.ac.uk/fac/soc/wbs/projects/emd • Wye et al. BMC Health Services Research (2015) 15:430 http://www.biomedcentral.com/1472-6963/15/430 • Wilson PM, Effects of a demand led knowledge translation service on the uptake and use of research evidence by NHS commissioners compared with lower intensity untargeted alternatives. HS&DR - 12/5002/18 http://www.nets.nihr.ac.uk/projects/hsdr/12500218
- 15. Bibliography 2/2 • Edwards et al Explaining Health Managers’ Information Seeking Behaviour and Use. Final report. NIHR Service Delivery and Organisation programme; 2013) http://www.nets.nihr.ac.uk/projects/hsdr/081808243 • CASH portal http://www.netvibes.com/keeping-up-to-date#Home • Evidence Works (Avon Primary Care Research Collaborative) (Avon Primary Care Research Collaborative, AHSN, NIHR CLAHRC West http://www.nhsevidencetoolkit.net/ • Commissioning Handbook for Librarians (NHS Librarians) http://commissioning.libraryservices.nhs.uk/ • KfH Learning Zone http://kfh.libraryservices.nhs.uk/learning- zone/specialist-and-technical-skills/
Editor's Notes
- My experience supporting day to day activity in a PCT/CCG But this should be useful to librarians from across the NHS especially in the light of current government policies such as Sustainability & Transformation Plans (STPs) and the Carter review which affect every NHS trust. Managers across the NHS will be looking for evidence to support transition, not just commissioners.
- As EPB is about ensuring the best practice for individual patients, Evidence based commissioning is about doing the best for the whole population, taking into account local and national context, public and patient opinions, demography and of course money. So if we think about the environment commissioners (and trust managers) are working in, health services are a business with business pressures, and activity targets and financial targets. They have political constraints as well as workforce and demographic issues. Commissioners are constantly in meetings, reading and writing reports with tight schedules, CCGs have many legal obligations around managing their business as well as issues relating to wider services, and shifting political goal posts.
- A study by Swann surveyed 345 individuals across 11 PCTs in 2010. - Demonstrated a plurality of evidence Clinical evidence we would all recognize, guidelines, clinical research, Royal Colleges, professional peer groups. Non clinical evidence – supporting evidence in terms of policies, toolkits, intelligence , benchmarking. Implementation Narrative resources –Include opinions, advice, stories, case studies. While clinical research usually aims to eliminate confounders and variables, these variables of setting are critical to understanding the workings of health services across different geographies. For example service availability, distances, workforce, and demography. You rarely get this level of detail when people describe services in research. Therefore case studies or talking to people may be the best way to understand the “evidence” behind a service.
- I looked at my weekly alerting bulletins for commissioners and CCGs over July. These do not include items on clinical practice, but service delivery. Out of 58 items non clinical “expert” groups comprise nearly a third, many of which will include case studies. The significance of much of this evidence is determined by who wrote it. Definitely not resources you find through an HDAS search alone.
- Clearly commissioners rely heavily on colleagues and personal experience. Informal sharing is an important part of the commissioning process. Mailing lists / alerts – keeping ahead of the curve/horizon scanning are important They look for the evidence themselves and that means google and all of its pitfalls, but judicious use of google is a good way to get some of the evidence they need. The research into info seeking behaviour always highlights how difficult it is to find the evidence. It is not conveniently placed or organised. NHS sources are constantly changing – think of NeLH, Specialist Collections, NHS Improvement (the old one), NHS III and the DH website itself. The exception is public health trained staff who have had training in finding and appraising evidence. But since the HSC Act and their move to LA they are one step removed from the informal commissioning discussions. Commissioners don’t think to ask libraries for this type of evidence, unless they have had previous contact with the library – a training course, induction etc. Finally- librarians too find it difficult to locate evidence for commissioners and managers.
- It is interesting to look at how evidence is used during the commissioning process. The epilepsy commissioning cycle I showed you earlier made the process moving evidence through the commissioning pipeline look smooth and unaffected by organisational processes. But, the reality is different. Evidence is constantly modified, added, discarded and reshaped throughout the commissioning process. The lack of evidence can lead to lengthy discussions do not lead to consensus and delays. Research shows that evidence is both gathered and used in a non systematic way throughout commissioning. All of this research matches my experience on the ground So how can librarians help?
- Over my time supporting commissioners I worked to develop: Develop a service model tailored to this customer base understand their information needs to provide the evidence is the most appropriate way. Some of the lessons I learnt:
- Find out what is business critical to my commissioners. Specific issues eg A&E, services under development, QIPP plans CQUINs, co-commissioning, NHS Improvement, Keogh, vanguards, PACS, MDT, Five year forward View, STP, Carter So if you are asked you understand the issues and ask sensible questions and tailor your services
- How are you going to find this evidence? HSJ (no print after next year). The key news resource Most commissioners/managers will get the daily news alerts. Their comms people should be keeping them abreast of the news and media stuff. Dig down to find the documents behind the story eg CCG board paper, report etc. Also helps up keep up to date with what is going on National policies -NHS E/ CQC /PHE/ NHS Improvement Expert bodies eg KF, Nuffield, Royal Colleges etc. Magazines/board papers – to find case studies Google – a key resource to dig into board papers and reports, much better than search engines on websites. Become a google expert. A real mixture of resources which you should not try to scan yourself. Use existing RSS feeds or alerting services eg NHS England has a number of different bulletins, Kings Fund Health Management & Policy Alert is a key resource both for their own and other resources. But sometimes it is useful to know if a page is updated, rather than an RSS feed, I use Watch That page where you are alerting if a particular page changes.
- Research says that for day to day business they want business style reports. And preferably before they know they need it. Commissioners want evidence presented in such a way that they can pick up the key points at a glance, can read a little more if it is interesting then look further using any links they are given. Look at Kings Fund reports – headlines in the form of bullet points, an executive summary and then the full report with references. The style I developed was very much in this pattern, both for research reports and alerting services. In CAS I aim for a title, author, date and three lines max (in which I make it clear why I have included the item) and a link. The research reports I produce usually took between 3 and 8 hours, so quite short. Clarify the topic, note exclusions and sources checked. Bring related material together (could be different reports, a website and case study) and highlight what makes the item relevant. I often include extracts from the reports themselves. That means you have to read the resources but commissioner may not. Organise the material in a logical way (theme, format, data) geographically or by topic. But it is important that it can be skimmed quickly. Include how long it has taken to prepare.
- Alerting services – really important to commissioners. Available to commissioners/manager and library staff. A quick win if you get it on target. Tell your contacts about alerts you think are relevant to them eg Kings Fund Health Management Alert, KF Integrated Care Bulletin. Sign up yourself. Don’t duplicate this scanning work. Current Alerting Service for Health (CASH) site under Health Functions & Management. Evidence Works Toolkit (Avon Primary Care Research Collaborative) - a guide to finding, appraising and applying the evidence aimed at commissioners across the West of England. A sister website on evaluations. Includes links to local NHS librarians. Commissioning Handbook - A resource specially for NHS Library Knowledge and Information staff to help you support commissioners more effectively. Brings together useful resources about the NHS, commissioning process and relating to specific diseases, populations and services. Includes searching advice and hot topics. Mailing lists – Commissioning list, LIS Medical Embedded librarians / Library services – need to be protected because experience is vital.
- Talking of skills Graduate evidence analyst pilot evaluation - the Assistant comments on the range of practical skills she had gained since taking on the role as well as knowledge of public health, epidemiology, evidence-based healthcare, local authority structure, local and national NHS and public health structure. This role encouraged evidence based commissioning and gave commissioners confidence in evidence questioning and gathering skills. KfH opportunities Don’t forget that there are knowledge staff sitting outside NHS library services.
- Bearing in mind the developments which are coming as a result of STPs and the new standards as result of Carter review on procurement librarians have a lot to offer to help managers by bringing together the important stuff they need to do their job. Every trust will be involved in these discussions, and every nHS library could be supporting the development of the new services. Build on existing relationships, knowledge, resources Work with other libraries – eg across your STP footprint, region Start asap, STP plan are due go out to consultation at end of October, we should be ready to answer the questions as they arise.