NHS commissioning is responsible for spending 2/3 of the NHS budget – around £72 billion in 2016/17 – to meet the health needs of the population. In making decisions on how to best allocate this resource, we would expect commissioners to seek out and apply the best available evidence: unlike clinical decisions made by health professionals on an individual patient basis, commissioning decisions can impact on hundreds of thousands of people. Examples include redesigning a service for people with diabetes to provide it outside hospital, or introducing new roles to support people with musculoskeletal disease.
What’s going on?
Although evidence based medicine (EBM) has been around for 20 years, influencing other healthcare disciplines, there are less incentives to facilitate evidence-informed decision making in commissioning.
In reality there is an unexplained variability in how commissioners use evidence and it takes many forms: activity data, ‘think tank’ publications (eg Kings Fund), patient feedback, knowledge, experience, NICE guidelines, networks and even Google. Less often research evidence is used: it is rarely favoured as it can be difficult to interpret and apply and, significantly, is not always presented appropriately to answer commissioners’ questions.
‘We have lots of commissioning activity going on, but not much real evidence about what works, little analysis, and not much real change in services.’ (Commissioning Manager)
Commissioning decisions are often complex and messy, carried out in a pressured environment. The context is key with environment (politics) and organisation (values, culture) having a strong influence. NHS commissioning requires a wide range of knowledge and juggling of priorities. Commissioners access and define health needs of a population, determine priorities, purchase appropriate services within available resources and monitor/evaluate to inform the next commissioning round.
Using evidence is particularly important in the current financial environment: NHS efficiency savings of £22bn are required by 2020 and demand on resources is increasing as people live longer with several long term conditions. The need to use evidence to guide investment/disinvestment decisions, avoid waste and to challenge assumptions is stronger than ever.
Commissioners are a mixed bag: some come from a clinical route, others formally trained managers (e.g. NHS training scheme) or have worked in managerial roles in other sectors. Despite the emphasis placed on clinical commissioning by the 2012 NHS reforms, the cultural and practical barriers to using evidence remain.
In working closely with commissioners, we recognize there are many barriers to accessing and using evidence. We have followed closely the work of the Alliance for Useful Evidence where recent publications have reflected our observations on barriers and solutions to improving the use of evidence. Presenting at the recent What Works Global Summit, we found it valuable to connect with peers in the fields of policing, education and justice, realizing the potential to share learning.
Last year, we produced a ‘Manifesto for Evidence Informed Health and Care Commissioning’ with the aim of making more connections to enable knowledge sharing and peer support.
The manifesto sets out ten key principles for enabling evidence-informed commissioning, highlighting collaboration, co-produced research and improved awareness. If you’re involved in commissioning, we invite you to get in touch – do these principles resonate with your context? What might we achieve through collective action, collaboration and networking?
Views expressed are the author’s own and do not necessarily represent those of the Alliance for Useful Evidence. Remember you can join us (it’s free and open to all) and find out more about the how we champion the use of evidence in social policy and practice.