Listas de verificación previas al arranque

In adapting and applying knowledge accessed through these conduits, two processes were regularly employed: contextualisation and engagement.

Contextualisation

Contextualisation involved taking information from elsewhere and applying a local lens or filter. Commissioners had an essential role in contextualising the knowledge to local circumstances, but

sometimes external providers had to undertake contextualisation as well so that the knowledge was fit for commissioners. When appropriating information from elsewhere, one commissioning manager commented

that someone‘always says our system is not like that’ (Clara, NHS commissioning manager), and so the

knowledge needed to be contextualised to overcome this hurdle. One commissioning manager said that

contextualisation was the‘crux’ of commissioning.

I think that’s the crux of our job. It’s really interesting, because you read what you read, and you find

out what you can, but then it has to be applied locally. And all localities are different, you know. If

you look at [our CCG], for instance, we’ve only X population in our entire area. Geographically it’s

relatively small and urban compared to say our neighbours in [county name]. So that alone says something about how you start to think about things. And a lot of activity, research, JSNAs, a lot of

Public Health driven sort of surveys about where your deprivation is– all that information is available.

And so you have to then balance best practice against what’s reality locally, what you’re doing already

good and bad locally.

Alan, commissioning manager

The inherent transferability between the original context where the information was generated and the local situation was important and participants varied in views on how close that matching had to be.

Karen:If evidence or trials show that it works elsewhere then we have to believe that it can work here too.

Carol:Agree but we can’t assume that it will all work here because the data elsewhere may say 200

but it won’t be 200 here. Need to look at all of the pieces not just one part.

Contextualisation repeatedly appeared in product deployment. The type of knowledge and information built into software tools was often based on academic research evidence or expert consensus that was not

UK based. Often, tools needed‘Anglicisation’. This contextualisation was crucial, as without high NHS

applicability clients tended to dismiss the tool. Some contextualisation was undertaken by external provider staff, but, to make some tools useful, NHS analysts provided further contextualisation for the local

health-care economy.

Moreover, NHS clients had to know what to do with the data and needed help applying data outputs to

commissioning decisions. Ideally, commissioners had access to an‘interpreter’ who was known and trusted

to assist with this type of contextualisation. For example, in one CCG, a CSU analyst attended meetings where she had a regular slot to present a dashboard and work through the implications of the data with committee members. In another CCG, a GP commissioner talked about his concern that, without a trusted interpreter, commercial providers might take advantage of GP commissioners.

But, you know, what do you do with that data? We know that it must be saying something to us, the fact that a little old lady has had three falls, the ambulances have been round a few times, that

probably is telling us something about her, that she’s not very stable. But it doesn’t tell us that she’s

somebody that necessarily needs to be assessed by the team. And when our team resources are really

very, very stretched, we’re in a bit of a dilemma. We’ve now got a waiting list for people to be

assessed, and half of them, I suspect, will be assessed and it will be decided that they hadn’t really got

a big problem at all. So somebody coming in and saying,‘Oh yeah, we recognise all of that, we can

do something with that,’ sounds superficially very appealing. Now some of it may be complete bullshit

and they may just be angling to get into the markets and that’s what worries me.

Roger, GP commissioner

Contextualisation was integral to the‘copy, adapt and paste’ conduit and manifested in interpersonal

relationships and people placement, where through relationships and by combining knowledge and expertise, knowledge could be transformed into a more useable, applicable form. Training on the tools alone did not appear to be sufficient in helping commissioners to maximise their use of the tools. The outputs had to be interpreted and contextualised by those who understood the tools, so that local commissioners could digest and apply the information. Otherwise, NHS clients did not know what to do with the data. Contextualisation was less evident in governance processes, although translating national and regional mandates required some contextualisation.

Engagement

Another knowledge transformation process was engagement. Engagement was about taking transformed

knowledge and exposing and refining it further by involving the‘right people’. The right people might

have important information or perspectives, be positioned to instigate behavioural change (or show reason why that could or should not happen) and/or could tap into local or national networks to make the initiative a success. Again, commissioners were crucially placed to undertake local engagement, but external providers also actively used engagement strategies.

Local commissioner-led engagement was evident with service redesign initiatives, whereby commissioners

drew on the experience of those‘round the table’ (Abbie, NHS commissioning manager). Moreover,

engagement of clinicians into commissioning initiatives was discussed across all case sites. For example, in one CCG meeting the group talked about progress on engaging ophthalmologists in developing a community service. Engaging GP practices was also a common topic.

And one other positive thing I think is that in previous times it’s been incredibly difficult to actually engage general practice in some of the quality improvement work because, understandably, you

know, independent contractors, getting GPs to come to meetings and do things if you can’t fund

them and things is quite difficult, and now obviously that is a role [for GP commissioners].

With appropriate governance, engagement was visible to ensure that the right people were involved in decision-making. This signalled that the relevant organisations had been consulted and took responsibility. Being perceived as engaging appropriately was a high priority with one CCG, where very large meetings with many different organisational representatives were held, although input from some was minimal (i.e. Public Health, Social Services). In another, the process of engagement led to a different (and smaller) mix of elected councillors and a lay representative as chairperson.

In one contract, engagement by the external provider was clearly implicated in the vicissitudes of the

contract’s success. The commercial provider first deployed a team of analysts with little commissioning

expertise or NHS knowledge and minimal focus on relationship building and engaging local commissioners. The NHS client complained. The commercial provider then allocated a cohort of new management

consultants, many with a background in the NHS, with a remit of‘commissioner engagement’ to help to

interpret and use the data. Some successfully developed interpersonal relationships. The NHS clients were happier. However about a year later, changes within the commercial provider meant that the emphasis shifted and engagement moved more to the background. Moreover, the commercial provider blocked NHS clients from having any direct contact with subcontractors of the tools because of concerns that the NHS clients would drop the main contractor in favour of the subcontractors. This stifled knowledge exchange. The contract was renegotiated; the termination date was brought forward by several months and the NHS clients directly contracted further training from a subcontracted company. Changing levels of commissioner engagement had an impact on the success of this contract.

In summary, engagement helped to spread, and further transformed, knowledge. Engagement was particularly necessary with product deployment, as ample data from this study suggested that without engaging the right people such as influential GPs and practice managers, as well as commissioners, the roll-out and use of software tools was frustrated. Interpersonal relationships enhanced product deployment and appeared to facilitate greater understanding (and possibly use) of the tool outputs generated.

Engagement was highly visible within governance.

Model of knowledge conduits and transformation processes

Figure 5 represents the findings of this chapter visually, setting out the relationships between the different

knowledge conduits and commissioners’ knowledge transformation processes. In Chapter 8, details from

vignettes will be added to the template below to provide examples.