Tipología de productos y servicios ofrecidos

The mechanisms whereby commissioners acquired knowledge included conversations, stories and documentation.

Verbal exchange was particularly well suited to the fast-paced, rapidly changing environment in which commissioners worked. Conversations were an important way of getting information quickly through chance encounters, formal meetings and informal gatherings. The contingent nature of these exchanges, however, meant that if a different combination of individuals had happened to meet, different knowledge would have been acquired and perhaps a different set of decisions would have been made.

. . . popping in to see various GPs on my way somewhere else because they had 5 minutes to spare

and wanted to chat. But we’ve come up with these ideas, and it’s just been because we’ve sat there

and had the time to chat.

Randall, freelance analyst

Knowledge was also acquired through stories. Sometimes stories were told to substantiate a viewpoint,

and sometimes stories about patients and services were recounted to appeal to‘common sense’

and/or make an emotional impact.

Daniel:So the example that we used, and that really hit the team, was a chap who was having

problems with dexterity in his hands– has anybody related this story to you already?

Interviewer:No, no, not this one.

Daniel:. . . And the clothing side, he was struggling to do his buttons and to do the collars of his shirt. They spent some time with him and, you know, the house was clean, he was a very proud person. And the old approach would either be to put in a package of care around help to dress himself, or making him wear some sort of T-shirt or something. Actually we were able to take his own formal shirts, and behind the buttons put in some Velcro, so that he could wear his own shirts and have that sense of self-esteem, and not have somebody coming in every day which, you know, the learning from the team was people lose their independence the more they have people doing for them.

So those types of simple things, but you can imagine, in a normal system, if you said,‘Well I need to

put some Velcro in,’ you know, they’d be hunting for the Velcro budget, we don’t have one, put in a

‘package of care’ around clothing!

Daniel, commercial consultant

Stories could be powerful in influencing commissioning decision-making. For example, a commissioning manager said that stories were important to persist with proposals through the lengthy, repeated decision-making cycles.

And I have often thought in the past you need the story of the change. Because ideally from the time

you’ve gone through health scrutiny committee, the CCG, other local groups, other stakeholder groups and

especially if you get to a procurement exercise where actually you might draw services to a close and you

know people may be TUPE’d [Transfer of Undertakings] or made redundant and there’s some heavy duty

consequences for people, you need a compelling story. And often that is much more powerful than data that you want to throw at people, and so having the clinical stories is really important and the patient’s story is really, really key.

Harry, NHS commissioning manager

But not everyone was in favour of stories. A Public Health consultant noted that GP commissioners tended

to be‘overly swayed by these hugely dramatic stories that clinicians would come in with based on

individual patient anecdotes’ (Mary, Public Health consultant).

Documentation

Although substantial knowledge acquisition occurred through informal conversation, more formal verbal exchanges such as meetings were recorded, to leave a paper trail documenting discussions for

accountability purposes. Commissioners had substantial access to other documentation, much of which was unsolicited. Documentation was often sent electronically. Documentation included performance, activity, financial and referral data from a range of health-care providers, directives and guidelines from the Department of Health and regional bodies, meeting papers, business cases, reports, patient satisfaction surveys, guidelines and pathways. Often key points were summarised on a side of A4 or an executive summary, possibly because the volume of reading was unmanageable. For example, governing board members had usually at least a dozen documents of several pages each to read before monthly meetings. Presumably to make this task easier, many documents had standardised cover sheet with information such as title, purpose of the paper and action required. In some cases, executive summaries of one page or shorter directly followed these cover sheets.

Despite this‘overabundance’ of information, which meant that CCGs were ‘absolutely swimming in data’,

a CCG chairperson said they had‘a staggering lack of . . . intelligent data’ (Simon, CCG chairperson).

One way of finding missing but desired information was through the internet. GP commissioners and

commissioning managers recounted how they used Google™ or Google Scholar to find the relevant

information to contribute to discussions with colleagues, inform thinking about service provision and substantiate the decisions already made.

I go onto Google Scholar or Google, and it’s not very difficult to type in key words like ‘CCG’ or ‘PBC’

or‘PCT budget allocation evidence’, and Google is phenomenal, and Google Scholar will obviously just

give you the articles, and you can usually get there on a single page, obviously go a little bit further, read some of the subreferences, etc., extract the key data and some of the graphs, put it onto a PowerPoint, and either present it at a board meeting or in one-to-one discussion with colleagues.

The process mentioned above of reading the subreferences, extracting the key data, entering findings onto a PowerPoint presentation and presenting the data to colleagues clearly illustrates the simultaneous processes of knowledge acquisition and transformation, as sifting, selecting, rejecting, synthesising and incorporating takes place to reshape the original knowledge (see Chapter 6, Ways knowledge is treated).

Useful but overlooked sources

Although where and how commissioners acquired information was important, the obvious sources that were overlooked were also interesting. For example, several participants from one commercial provider pointed out the vast number of good-quality data that commissioners did not use, including Public Health data sets. Another former commissioning manager recounted how she had been unaware of the wealth of information available to her from internal sources when she had worked within the NHS, and so had not known what to ask for.

Kirsten:. . . when they [commercial providers] came in and said,‘Who is driving your costs?’ at which

point I was like,‘What do you mean? I don’t understand that question’. I’ve got this demographic. I’ve

got this population, deprived population here and here. I’ve got this overall growth in population, and

this wodge of money at that hospital, and that wodge of money at this hospital. That was my data

points. And they came in and said,‘Well who is driving your costs?’ and came back with a pile of

paper this high saying,‘All these people have been in hospital more than three times in the last

12 months, they’re driving your costs’. I didn’t know I had that data, I didn’t know to ask for it, and

now I know.

Interviewer:And where did they get that data from?

Kirsten:From my own IMT [information management technology] department!

Kirsten, commercial consultant