Emer Brangan

Evidence based policy making and the 'art' of commissioning - how English healthcare commissioners access and use information and academic research in 'real life' decision-making: an empirical qualitative study.

BackgroundPolicymakers such as English healthcare commissioners are encouraged to adopt ‘evidence-based policy-making’, with ‘evidence’ defined by researchers as academic research. To learn how academic research can influence policy, researchers need to know more about commissioning, commissioners’ information seeking behaviour and the role of research in their decisions.MethodsIn case studies of four commissioning organisations, we interviewed 52 people including clinical and managerial commissioners, observed 14 commissioning meetings and collected documentation e.g. meeting minutes and reports. Using constant comparison, data were coded, summarised and analysed to facilitate cross case comparison.ResultsThe ‘art of commissioning’ entails juggling competing agendas, priorities, power relationships, demands and personal inclinations to build a persuasive, compelling case. Policymakers sought information to identify options, navigate ways through, justify decisions and convince others to approve and/or follow the suggested course. ‘Evidence-based policy-making’ usually meant pragmatic selection of ‘evidence’ such as best practice guidance, clinicians’ and users’ views of services and innovations from elsewhere. Inconclusive or negative research was unhelpful in developing policymaking plans and did not inform disinvestment decisions. Information was exchanged through conversations and stories, which were fast, flexible and suited the rapidly changing world of policymaking. Local data often trumped national or research-based evidence. Local evaluations were more useful than academic research.DiscussionCommissioners are highly pragmatic and will only use information that helps them create a compelling case for action.Therefore, researchers need to start producing more useful information.ConclusionsTo influence policymakers’ decisions, researchers need to 1) learn more about local policymakers’ priorities 2) develop relationships of mutual benefit 3) use verbal instead of writtencommunication 4) work with intermediaries such as public health consultants and 5) co-produce local evaluations.

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange.

Objectives The use of external consultants from private and not-for-profit providers in the National Health Service (NHS) is intended to improve the quality of commissioning. The aim of this study was to learn about the support offered to healthcare commissioners, how external consultants and their clients work together and the perceived impact on the quality of commissioning. Setting NHS commissioning organisations and private and not-for-profit providers. Design Mixed methods case study of eight cases. Data collection 92 interviews with external consultants (n=36), their clients (n=47) and others (n=9). Observation of 25 training events and meetings. Documentation, for example, meeting minutes and reports. Analysis Constant comparison. Data were coded, summarised and analysed by the research team with a coding framework to facilitate cross-case comparison. Results In the four contracts presented here, external providers offered technical solutions (eg, software tools), outsourcing and expertise including project management, data interpretation and brokering relationships with experts. In assessing perceived impact on quality of commissioning, two contracts had limited value, one had short-term benefits and one provided short and longer term benefits. Contracts with commissioners actively learning, embedding and applying new skills were more valued. Other elements of success were: (1) addressing clearly agreed problems of relevance to managerial and operational staff (2) solutions co-produced at all organisational levels (3) external consultants working directly with clients to interpret data outputs to inform locally contextualised commissioning strategies. Without explicit knowledge exchange strategies, outsourcing commissioning to external providers resulted in the NHS clients becoming dependent. Conclusions NHS commissioning will be disadvantaged if commissioners both fail to learn in the short term from the knowledge of external providers and in the longer term lose local skills. Knowledge exchange mechanisms are a vital component of commissioning and should be embedded in external provider contracts.

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like ‘urgent’ and ‘emergency’ was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around ‘inappropriate’ patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Tackling non-communicable diseases: Get the social scientists on board

Dear Editors, Momentum has been building within the campaign for action on global non-communicable diseases (NCDs), with September 2011’s United Nations’ declaration acknowledging that “the global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century”. At a symposium held on 25 April 2012 to mark the launch of the Centre for Global NCDs at the London School of Hygiene and Tropical Medicine, Professor Baron Peter Piot talked about the importance of ‘learning while we are sailing’. The theme of the symposium was from research to action, but e as Professor Baron Piot and several other speakers pointed out e much research remains to be done, particularly in lowand middle-income country contexts. We do need to take action based on the knowledge we already have, much of it generated by researchers in the field of public health, and extensive scientific evidence was presented over the course of the day (e.g. on priority actions for prevention using salt and tobacco control). However, another (more elusive) theme was also raised by several speakers. We have to find a way to grasp the agendas of social justice, rights and equity: the causes of the causes. Such an endeavour certainly fits with the symposium’s calls for bold and ambitious solutions, and a joined-up approach which allows this to be about health in its broadest sense, and not single-disease constituencies. However, it is also messy, challenging and intimidating. What do you do when your data suggest, as mine did in a recent study of NCDs in a South African township, that unemployment is the biggest upstream factor affecting local people’s health and well-being? That so-called ‘health behaviours’ are usually embedded in broader issues, and not amenable to change in isolation? It is easy to return to the safety of what we can measure relatively easily, and can see a way to do something about. However, there are people out there whose whole business of research is about social determinants; about justice, rights and equity. Sociologists, anthropologists, political scientists, economists: why are they out there when we could do with a few more of them in here? If sufficient numbers haven’t yet figured out that this is an area where they can make a difference e well, go and draw them in. The myths that NCDs are strictly for the medics to think about, or that they mainly affect middle-class males, may need overturning in schools of sociology, development studies, politics, economics and anthropology too, but these disciplines have knowledge, skills and experience which can complement those already embodied within the global NCD movement. It won’t necessarily be easy; such an interdisciplinary partnership will require an inclusive, although still rigorous, approach to what constitutes knowledge and evidence. The ‘image problem’ of NCDs was also raised at the symposium e how do we present stories about people, not diseases, to win hearts and minds to the cause? Anthropological research is big on life stories: I have 40 of them from that South African township, which I think few people would fail to be moved by. Towards the end of the day, an audience member from HelpAge International asked where ‘the people’ were in this global movement, especially the people in poor or excluded communities in lowand middle-income countries, who we now know are particularly vulnerable to NCDs. He has a point. They do need to be better represented in taking this forward. Maybe the social scientists will bring them in for us. It is a formidable task. Let’s not try and do it alone.

Exploring the Relationship between General Practice Characteristics and Attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10 - 2012/2013: a Longitudinal Study

BackgroundThe UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.MethodsA longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients’ emergency attendance rates and patients’ reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.ResultsPractice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (−0.26 per 1% increase, 95%CI −0.45 to −0.08).ConclusionPractices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

Staying well in a South African Township:: Stories from Public Health and Sociology

The current approach to preventing noncommunicable diseases1 (NCDs) in low— and middle-income countries draws heavily on the disciplines of public health and biomedicine, which unsurprisingly construct health as a dominant normative goal and a central component of wellbeing. The research which this chapter draws on was driven by my sense that something important was missing from much policy on NCD prevention: a broader understanding of how health and the so-called health behaviours2 implicated in causing NCDs were related to wellbeing, particularly in very challenging environments such as a South African township. It seemed to me that one of the reasons that such an understanding was lacking was the approach to knowledge which was being taken: the discourse around public health policy on prevention was ‘expert’ driven; the vast majority of the research on which policy was based was quantitative and had been carried out in high-income countries; and the ‘public’ were often cast as a group to be manipulated in order to change their behaviour, rather than as stakeholders with knowledge, values and reasons which warranted respectful attention. In order to explore this, I carried out qualitative research alongside a quantitative epidemiological study which was already underway in a township in South Africa. This chapter presents some of the stories which the combined data told and considers the implications of the different disciplinary approaches for the ideas about health and wellbeing which emerged.

Integration of research and practice to improve public health and healthcare delivery through a collaborative 'Health Integration Team' model - a qualitative investigation

BackgroundEconomic considerations and the requirement to ensure the quality, safety and integration of research with health and social care provision have given rise to local developments of collaborative organisational forms and strategies to span the translational gaps. One such model – the Health Integration Team (HIT) model in Bristol in the United Kingdom (UK) - brings together National Health Service (NHS) organisations, universities, local authorities, patients and the public to facilitate the systematic application of evidence to promote integration across healthcare pathways. This study aimed to (1) provide empirical evidence documenting the evolution of the model; (2) to identify the social and organisational processes and theory of change underlying healthcare knowledge and practice; and (3) elucidate the key aspects of the HIT model for future development and translation to other localities.MethodsContemporaneous documents were analysed, using procedures associated with Framework Analysis to produce summarised data for descriptive accounts. In-depth interviews were undertaken with key informants and analysed thematically. Comparative methods were applied to further analyse the two data sets.ResultsOne hundred forty documents were analysed and 10 interviews conducted with individuals in leadership positions in the universities, NHS commissioning and provider organisations involved in the design and implementation of the HIT model. Data coalesced around four overarching themes: ‘Whole system’ engagement, requiring the active recruitment of all those who have a stake in the area of practice being considered, and ‘collaboration’ to enable coproduction were identified as ‘process’ themes. System-level integration and innovation were identified as potential ‘outcomes’ with far-reaching impacts on population health and service delivery.ConclusionThe HIT model emerged as a particular response to the perceived need for integration of research and practice to improve public health and healthcare delivery at a time of considerable organisational turmoil and financial constraints. The concept gained momentum and will likely be of interest to those involved in setting up similar arrangements, and researchers in the social and implementation sciences with an interest in their evaluation.

Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the West of England

Objectives Early warning scores were developed to improve recognition of clinical deterioration in acute hospital settings. In England, the National Early Warning Score (NEWS) is increasingly being recommended at a national level for use outside such settings. In 2015, the West of England Academic Health Science Network supported the roll-out of NEWS across a range of non-acute-hospital healthcare sectors. Research on the use of NEWS outside acute hospitals is limited. The objective of this study was to explore staff experiences of using NEWS in these new settings. Design Thematic analysis of qualitative semi-structured interviews with purposefully sampled healthcare staff. Setting West of England healthcare settings where NEWS was being used outside acute hospitals—primary care, ambulance, referral management, community and mental health services. Participants Twenty-five healthcare staff interviewed from primary care (9), ambulance (3), referral management/acute interface (5), community (4) and mental health services (3), and service commissioning (1). Results Participants reported that NEWS could support clinical decision-making around escalation of care, and provide a clear means of communicating clinical acuity between clinicians and across different healthcare organisations. Challenges with implementing NEWS varied—in primary care, clinicians had to select patients for NEWS and adopt different methods of clinical assessment, whereas for paramedics it fitted well with usual clinical practice and was used for all patients. In community services and mental health, modifications were ‘needed’ to make the tool relevant to some patient populations. Conclusions This study demonstrated that while NEWS can work for staff outside acute hospital settings, the potential for routine clinical practice to accommodate NEWS in such settings varied. A tailored approach to implementation in different settings, incorporating guidance supported by further research on the use of NEWS with specific patient groups in community settings, may be beneficial, and enhance staff confidence in the tool.