Understanding the work done by NHS commissioning managers: an exploration of the microprocesses underlying day-to-day sensemaking in UK primary care organisations

The usage of data in NHS primary care commissioning: a realist evaluation

BACKGROUND

To improve health outcomes and address mounting costs pressures, policy-makers have encouraged primary care commissioners in the British National Health Service (NHS) to increase the usage of data in decision-making. However, there exists limited research on this topic. In this study, we aimed to understand how and why primary care commissioners use data (i.e. quantitative, statistical information) to inform commissioning, and what outcomes this leads to.

METHODS

A realist evaluation was completed to create context-mechanism-outcome configurations (CMOs) relating to the contexts influencing the usage of data in primary care commissioning. Using a realist logic of analysis and drawing on substantive theories, we analysed qualitative content from 30 interviews and 51 meetings (51 recordings and 19 accompanying meeting minutes) to develop CMOs. Purposive sampling was used to recruit interviewees from diverse backgrounds.

RESULTS

Thirty-five CMOs were formed, resulting in an overarching realist programme theory. Thirteen CMOs were identical and 3 were truncated versions of those formed in an existing realist synthesis on the same topic. Seven entirely new CMOs, and 12 refined and enhanced CMOs vis-à-vis the synthesis were created. The findings included CMOs containing contexts which facilitated the usage of data, including the presence of a data champion and commissioners' perceptions that external providers offered new skillsets and types of data. Other CMOs included contexts presenting barriers to using data, such as data not being presented in an interoperable way with consistent definitions, or financial pressures inhibiting commissioners' abilities to make evidence-based decisions.

CONCLUSIONS

Commissioners are enthusiastic about using data as a source of information, a tool to stimulate improvements, and a warrant for decision-making. However, they also face considerable challenges when using them. There are replicable contexts available to facilitate commissioners' usage of data, which we used to inform policy recommendations. The findings of this study and our recommendations are pertinent in light of governments' increasing commitment to data-driven commissioning and health policy-making.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Negotiating commissioning pathways for the successful implementation of innovative health technology in primary care

Background

Commissioning innovative health technologies is typically complex and multi-faceted. Drawing on the negotiated order perspective, we explore the process by which commissioning organisations make their decisions to commission innovative health technologies. The empirical backdrop to this discussion is provided by a case study exploring the commissioning considerations for a new photoplethysmography-based diagnostic technology for peripheral arterial disease in primary care in the UK.

Methods

The research involved an empirical case study of four Clinical Commissioning Groups (CCGs) involved in the commissioning of services in primary and secondary care. Semi-structured in-depth interviews (16 in total) and two focus groups (a total of eight people participated, four in each group) were conducted with key individuals involved in commissioning services in the NHS including (i) senior NHS clinical leaders and directors (ii) commissioners and health care managers across CCGs and (iii) local general practitioners.

Results

Commissioning of a new diagnostic technology for peripheral arterial disease in primary care involves high levels of protracted negotiations over funding between providers and commissioners, alliance building, conflict resolution and compromise of objectives where the outcomes of change are highly contingent upon interventions made across different care settings. Our evidence illustrates how reconfigurations of inter-organisational relations, and of clinical and related work practices required for the successful implementation of a new technology could become the major challenge in commissioning negotiations.

Conclusions

Innovative health technologies such as the diagnostic technology for peripheral arterial disease are commissioned in care pathways where the value of such technology is realised by those delivering care to patients. The detail of how care pathways are commissioned is complex and involves high degrees of uncertainty concerning such issues as prioritisation decisions, patient benefits, clinical buy-in, value for money and unintended consequences. Recent developments in the new care models and integrated care systems (ICSs) in the UK offer a unique opportunity for the successful commissioning arrangements of innovative health technologies in primary care such as the new diagnostic technology for peripheral arterial disease.

A web-based self-management programme for people with type 2 diabetes: the HeLP-Diabetes research programme including RCT

Background

In the UK, 6% of the UK population have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Diabetes mellitus accounts for 10% of NHS expenditure (£14B annually). Good self-management may improve health outcomes. NHS policy is to refer all people with T2DM to structured education, on diagnosis, to improve their self-management skills, with annual reinforcement thereafter. However, uptake remains low (5.6% in 2014–15). Almost all structured education is group based, which may not suit people who work, who have family or other caring commitments or who simply do not like group-based formats. Moreover, patient needs vary with time and a single education session at diagnosis is unlikely to meet these evolving needs. A web-based programme may increase uptake.

Objectives

Our aim was to develop, evaluate and implement a web-based self-management programme for people with T2DM at any stage of their illness journey, with the goal of improving access to, and uptake of, self-management support, thereby improving health outcomes in a cost-effective manner. Specific objectives were to (1) develop an evidence-based theoretically informed programme that was acceptable to patients and health-care professionals (HCPs) and that could be readily implemented within routine NHS care, (2) determine the clinical effectiveness and cost-effectiveness of the programme compared with usual care and (3) determine how best to integrate the programme into routine care.

Design

There were five linked work packages (WPs). WP A determined patient requirements and WP B determined HCP requirements for the self-management programme. WP C developed and user-tested the Healthy Living for People with type 2 Diabetes (HeLP-Diabetes) programme. WP D was an individually randomised controlled trial in primary care with a health economic analysis. WP E used a mixed-methods and case-study design to study the potential for implementing the HeLP-Diabetes programme within routine NHS practice.

Setting

English primary care.

Participants

People with T2DM (WPs A, D and E) or HCPs caring for people with T2DM (WPs B, C and E).

Intervention

The HeLP-Diabetes programme; an evidence-based theoretically informed web-based self-management programme for people with T2DM at all stages of their illness journey, developed using participatory design principles.

Main outcome measures

WPs A and B provided data on user ‘wants and needs’, including factors that would improve the uptake and accessibility of the HeLP-Diabetes programme. The outcome for WP C was the HeLP-Diabetes programme itself. The trial (WP D) had two outcomes measures: glycated haemoglobin (HbA1c) level and diabetes mellitus-related distress, as measured with the Problem Areas in Diabetes (PAID) scale. The implementation outcomes (WP E) were the adoption and uptake at clinical commissioning group, general practice and patient levels and the identification of key barriers and facilitators.

Results

Data from WPs A and B supported our holistic approach and addressed all areas of self-management (medical, emotional and role management). HCPs voiced concerns about linkage with the electronic medical records (EMRs) and supporting patients to use the programme. The HeLP-Diabetes programme was developed and user-tested in WP C. The trial (WP D) recruited to target (n = 374), achieved follow-up rates of over 80% and the intention-to-treat analysis showed that there was an additional improvement in HbA1c levels at 12 months in the intervention group [mean difference –0.24%, 95% confidence interval (CI) –0.44% to –0.049%]. There was no difference in overall PAID score levels (mean difference –1.5 points, 95% CI –3.9 to 0.9 points). The within-trial health economic analysis found that incremental costs were lower in the intervention group than in the control group (mean difference –£111, 95% CI –£384 to £136) and the quality-adjusted life-years (QALYs) were higher (mean difference 0.02 QALYs, 95% CI 0.000 to 0.044 QALYs), meaning that the HeLP-Diabetes programme group dominated the control group. In WP E, we found that the HeLP-Diabetes programme could be successfully implemented in primary care. General practices that supported people in registering for the HeLP-Diabetes programme had better uptake and registered patients from a wider demographic than those relying on patient self-registration. Some HCPs were reluctant to do this, as they did not see it as part of their professional role.

Limitations

We were unable to link the HeLP-Diabetes programme with the EMRs or to determine the effects of the HeLP-Diabetes programme on users in the implementation study.

Conclusions

The HeLP-Diabetes programme is an effective self-management support programme that is implementable in primary care.

Future work

The HeLP-Diabetes research team will explore the following in future work: research to determine how to improve patient uptake of self-management support; develop and evaluate a structured digital educational pathway for newly diagnosed people; develop and evaluate a digital T2DM prevention programme; and the national implementation of the HeLP-Diabetes programme.

Trial registration

Research Ethics Committee reference number 10/H0722/86 for WPs A–C; Research Ethics Committee reference number 12/LO/1571 and UK Clinical Research Network/National Institute for Health Research (NIHR) Portfolio 13563 for WP D; and Research Ethics Committee 13/EM/0033 for WP E. In addition, for WP D, the study was registered with the International Standard Randomised Controlled Trial Register as reference number ISRCTN02123133.

Funding details

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 5. See the NIHR Journals Library website for further project information.

Integrated care

Purpose

The purpose of this paper is to try and understand how several organisations in one area in England are working together to develop an integrated care programme. Weick’s (1995) concept of sensemaking is used as a lens to examine how the organisations are working collaboratively and maintaining the programme.

Design/methodology/approach

Qualitative methods included: non-participant observations of meetings, interviews with key stakeholders and the collection of documents relating to the programme. These provided wider contextual information about the programme. Comprehensive field notes were taken during observations and analysed alongside interview transcriptions using NVIVO software.

Findings

This paper illustrates the importance of the construction of a shared identity across all organisations involved in the programme. Furthermore, the wider policy discourse impacted on how the programme developed and influenced how organisations worked together.

Originality/value

The role of leaders from all organisations involved in the programme was of significance to the overall development of the programme and the sustained momentum behind the programme. Leaders were able to generate a “narrative of success” to drive the programme forward. This is of particular relevance to evaluators, highlighting the importance of using multiple methods to allow researchers to probe beneath the surface of programmes to ensure that evidence moves beyond this public narrative.

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

BACKGROUND

Policymakers 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.

METHODS

In 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.

RESULTS

The '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.

DISCUSSION

Commissioners 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.

CONCLUSIONS

To 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.

Knowledge exchange in health-care commissioning: case studies of the use of commercial, not-for-profit and public sector agencies, 2011–14

Background

English health-care commissioners from the NHS need information to commission effectively. In the light of new legislation in 2012, new ‘external’ organisations were created such as commissioning support units (CSUs), public health departments moved into local authorities and ‘external’ provider organisations such as commercial and not-for-profit agencies and freelance consultants were encouraged. The aim of this research from 2011 to 2014 was to study knowledge exchange between these external providers and health-care commissioners to learn about knowledge acquisition and transformation, the role of external providers and the benefits of contracts between external providers and health-care commissioners.

Methods

Using a case study design, we collected data from eight cases, where commercial and not-for-profit organisations were contracted. We conducted 92 interviews with external providers (n = 36), their clients (n = 47) and others (n = 9), observed 25 training events and meetings and collected various documentation including meeting minutes, reports and websites. Using constant comparison, data were analysed thematically using a coding framework and summaries of cases.

Results

In juggling competing agendas, commissioners pragmatically accessed and used information to build a cohesive, persuasive case to plot a course of action, convince others and justify decisions. Local data often trumped national or research-based information. Conversations and stories were fast, flexible and suited to the continually changing commissioning environment. Academic research evidence was occasionally explicitly sought, but usually came predigested via National Institute of Health and Care Excellence guidance, software tools and general practitioner clinical knowledge. Negative research evidence did not trigger discussions of disinvestment opportunities. Every commissioning organisation studied had its own unique blend of three types of commissioning models: clinical commissioning, integrated health and social care and commercial provider. Different types of information were privileged in each model. Commissioners regularly accessed information through five main conduits: (1) interpersonal relationships; (2) people placement (embedded staff); (3) governance (e.g. Department of Health directives); (4) ‘copy, adapt and paste’ (e.g. best practice elsewhere); and (5) product deployment (e.g. software tools). Interpersonal relationships appeared most crucial in influencing commissioning decisions. In transforming knowledge, commissioners undertook repeated, iterative processes ofcontextualisationusing a local lens andengagementto refine the knowledge and ensure that the ‘right people’ were on board. Knowledge became transformed, reshaped and repackaged in the act of acquisition and through these processes as commissioners manoeuvred knowledge through the system. External providers were contracted for their skills and expertise in project management, forecast modelling, event management, pathway development and software tool development. Trust and usability influenced clients’ views on the usefulness of external providers, for example the motivations of Public Health and CSUs were more trusted, but the usefulness of their output was variable. Among the commercial and not-for-profit agencies in this study, one was not very successful, as the NHS clients thought that the external provider added little of extra value. With another, the benefits were largely still notional and with a third views were largely positive, with some concerns about expense. Analysts often benefited more than those making commissioning decisions.

Conclusions

External providers who maximised their use of the different conduits and produced something of value beyond what was locally available appeared more successful. The long-standing schism between analysts and commissioners blunted the impact of some contracts on commissioners’ decision-making. To capitalise on the expertise of external providers, wherever possible, contracts should include explicit skills development and knowledge transfer components.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Towards a framework for enhancing procurement and supply chain management practice in the NHS: lessons for managers and clinicians from a synthesis of the theoretical and empirical literature

Background

This review provides intelligence to NHS managers and clinicians involved in commissioning and procurement of non-pay goods and services. It does this in the light of ongoing pressure for the NHS to save money through a combination of cost cutting, productivity improvements and innovation in service delivery, and in the context of new commissioning structures developing as a result of the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. Chapter 7. London: The Stationery Office; 2012).

Objectives

We explore the main strands of the literature about procurement and supply chain management (P&SCM); consider the extent to which existing evidence on the experiences of NHS managers and clinicians involved in commissioning and procurement matches these theories; assess how the empirical evidence about different P&SCM practices and techniques in different countries and sectors might contribute to better commissioning and procurement; and map and evaluate different approaches to improving P&SCM practice.

Review method

We use a realist review method, which emphasises the contingent nature of evidence and addresses questions about what works in which settings, for whom, in what circumstances and why. Adopting realist review principles, the research questions and emerging findings were sense-checked and refined with an advisory group of 16 people. An initial key term search was conducted in October 2013 across relevant electronic bibliographic databases. To ensure quality, the bulk of the search focused on peer-reviewed journals, though this criterion was relaxed where appropriate to capture NHS-related evidence. After a number of stages of sifting, quality checking and updating, 879 texts were identified for full review.

Results

Four literatures were identified: organisational buying behaviour; economics of contracting; networks and interorganisational relationships; and integrated supply chain management (SCM). Theories were clustered by their primary explanatory focus on a particular phase in the P&SCM process. Evidence on NHS commissioning and procurement practice was found in terms of each of these phases, although there were also knowledge gaps relating to decision-making roles, processes and criteria at work in commissioning organisations; the impact of power on collaborative interorganisational relationships over time; and the scope to apply integrated SCM thinking and techniques to supply chains delivering physical goods to the NHS. Evidence on P&SCM practices and techniques beyond the NHS was found to be highly fragmented and at times contradictory but, overall, demonstrated that matching management practice appropriately with context is crucial.

Conclusions

We found that the P&SCM process involves multiple contexts, phases and actors. There are also a wide variety of practices that can be used in each phase of the P&SCM process. Thinking about how practice might be improved in the NHS requires an approach that enables the simplification of the complex interplay of factors in the P&SCM process. Portfolio-based approaches, which provide a contingent approach to considering these factors, are recommended. Future work should focus on conflicting preferences in NHS commissioning and procurement and the role of power and politics in conflict resolution; the impact of power on the scope for collaboration in health-care networks; and the scope to apply integrated SCM practices in NHS procurement organisations.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Reforming primary healthcare: from public policy to organizational change

Purpose

– Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec.

Design/methodology/approach

– An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis.

Findings

– The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of “intermediate change” and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery.

Research limitations/implications

– This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation.

Practical implications

– The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes.

Originality/value

– This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design.