The capacity of health service commissioners to use evidence: a case study

Abstract

Clinical Commissioning Groups (CCGs) lead a network of organisations that plan and make decisions about what services to provide through the NHS. To make commissioning decisions based on evidence, CCGs need to develop capacity to acquire and use evidence of different types. CCGs can not only draw on evidence about what is most clinically effective or cost-effective, but also consider patient experience and local knowledge held by doctors. Policy-makers recognise this and require that CCG-led commissioning networks include general practitioners (GPs), so that their knowledge about the local population and services is considered, and patient and public involvement (PPI) representatives, so that patient experience is considered, in their decision-making. In the context of older persons’ care and potentially avoidable admissions, CCGs should also seek to integrate evidence from health-care organisations with that held by social care organisations (adult social care departments in local authorities).Funded by the National Institute for Health Research, through its Health Services and Delivery Research programme (12/5002/01), our research empirically focuses on a tracer study of reducing potentially avoidable admissions of older people into acute hospitals. Our study examines the critical review capacity of 13 cases of representative (region, size, urban/rural) commissioning networks in England to acquire and use different types of evidence to inform their decisions about service interventions.Conceptually, we apply a specific model of knowledge mobilisation, absorptive capacity (ACAP), which details the antecedents and dimensions of an organisation’s capacity to acquire and use knowledge for enhanced performance. Drawing on interviews with commissioning managers, GPs, PPI representatives and other relevant stakeholders, our study highlights that commissioning networks led by CCGs lack capacity to use different types of evidence to make well-informed decisions. We find that the use of local knowledge about patients, and the patient experience of services, may be poor. CCGs make poor use of data about population need and existing services, which the external organisation (commissioning support units) potentially provides. Voluntary organisations have a role to play in providing evidence about gaps in patient need and local services. Finally, given the need for health and social care organisations to work together, specifically in older people’s care, there is a need to integrate different evidence and perspectives in decision-making across health and social care organisations. Based on the above, our study develops a self-development psychometric tool for CCG-led commissioning networks to reflect on and enhance their critical review capacity with respect to the acquisition and use of different types of evidence.Limitations are threefold. First, we sampled only 13 cases. Nevertheless, we have attempted to generate transferable lessons for other commissioning networks through theoretical analysis, drawing on dimensions of ACAP to highlight factors influencing evidence use. Second, GPs engaged variably across the cases with our study. Others might carry out a more specific study of GP involvement in commissioning. Third, at the inception of our study, CCGs were fledgling organisations. Others may study development of critical review capacity of CCGs as their relationships developed across the commissioning network.