Future research evolving from this study has already been commissioned. The study lead obtained a NIHR Knowledge Mobilisation fellowship with the aim of increasing collaborations between NHS commissioners and primary care academics. This will run from June 2014 to June 2017. Specifically, she will develop communities of practice consisting of patients, clinicians, researchers and commissioners to evaluate
health-care services, drawing on researchers’ methodological knowledge. This work will be heavily
informed by the learning from this study. Furthermore, we have identified several areas where further research would be helpful.
Replication
There would be some merit in repeating this work, given that it was carried out at a time of particular turmoil in the NHS, to see the extent to which those organisational exigencies affected some of the findings.
Knowledge exchange
l To what extent do clinicians and managers from primary, secondary and community care draw on the
conduits and transformation processes identified in our study? What is their impact and how is that affected by different circumstances?
l Are these knowledge exchange conduits amenable to deliberate and productive manipulation and, if
so, to what extent do such interventions improve the process and outcomes of knowledge exchange?
Commissioning
l Can and should NHS and commercial health-care providers be commissioned in the same way?
l What are the‘core skills’ required for the commissioning of the health service and where should
they reside?
Public Health
l What are the characteristics of public health departments that successfully meet commissioners’ needs?
Commissioning support units
l How do the role, training and skills of health-care analysts need to change to make working in CSUs
an attractive option?
l How can CSUs and commercial/not-for-profit providers work together to maximise
knowledge exchange?
Commercial, not-for-profit and freelance providers
l What are measurable outcomes of utilisation of commercial and not-for-profit agencies and how do
they compare?
l Given that this study focused mainly on commercial providers who offered software tools, what is the
contribution of commercial providers that primarily provide management consultancy?
l How successful is the‘Lead Provider Framework’ in identifying and securing effective collaborations?
Conclusion
Commissioners had to influence and collaborate with many external and internal parties to build a cohesive case for taking any particular commissioning decision. Amid a web of competing agendas, priorities and power relationships, as well as their own professional, organisational and political norms,
commissioners had to make the‘best’ decision that the often conflicting pressures, constraints and
tensions allowed. The‘art’ or ‘craft’ of commissioning was, in essence, pulling together the appropriate
knowledge and information, including the tools for producing it to satisfy competing agendas, and manoeuvre it through a complex system. That process inevitably meant that knowledge was continually being altered to meet those multifaceted requirements.
We identified three models of commissioning in our particular case studies: clinical, integrated health and social care, and commercial provider commissioning. Different types of knowledge were privileged in the different models. Local clinical knowledge from GPs was prioritised in the clinical commissioning model,
service user knowledge was key in the integrated health and social care model, and analysts’ knowledge
of capturing and interpreting data was crucial in the commercial provider model. All commissioning organisations displayed various blends of these models.
Commissioners were highly pragmatic in their use of knowledge. Research evidence usually appeared in a digested format such as NICE guidelines and often required further contextualisation, such as locally devised clinical briefings or reviews, before being considered. Commissioners did not appear to consider the ways that negative research evidence that could inform disinvestment opportunities.
We identified five main conduits that commissioners used to access and transform knowledge. They were:
l interpersonal relationships
l people placement (embedded staff)
l governance (e.g. national directives, local procedures)
l copy, adapt and paste (best practice from elsewhere)
l product deployment (software tools).
Within those conduits, media such as conversations and stories fitted particularly well with the
fast-changing, flexible world of commissioning, and often‘trumped’ hard data that could be questioned or
sidelined on account of their low perceived usability. Local data often were more persuasive than national or research-based information.
As knowledge was exchanged through these conduits, it was iteratively refocused, reshaped or rejected, largely through two transformative processes:
l contextualisation (amending it to suit local circumstances), and
l engagement (involving the key players for whom the knowledge would have an impact).
This was true both in the act of obtaining the knowledge, and subsequently when it was being actively reshaped and repackaged as moved between and within organisations and key personnel. These processes were redolent of some of the notions that underpinned our analysis, especially collective organisational
sensemaking,‘the social life of knowledge’, the development of collective mindlines, and the role of
communities of practice.
External providers that maximised their use of these conduits and transformation processes were more successful. Interpersonal relationships were especially important to help contextualise the knowledge for
local application and engage the‘right people’ to refine the knowledge further. External providers that
mainly targeted NHS/CSU analysts (e.g. through product deployment alone) were less likely to influence commissioners, because of the long-standing schism between analysts and commissioners. Some
commercial providers bridged this gap by creating interdisciplinary teams of analysts, project managers and clinicians. But elsewhere, because of this split, the sporadic use of the knowledge conduits and the variable production of output over and above what was already available, many contracts within our case studies were perceived by our research participants as being only partly successful. Success was, however, difficult to define or assess, let alone quantify. Trust and usability influenced client views on usefulness of external provider contributions.
An impact of the 2012 Health and Social Care Act was to further distance information producers
(i.e. health-care analysts) from information users (i.e. commissioners) by creating organisational boundaries that were barriers to knowledge exchange. Consequently, commissioning organisations often did not capitalise on contractual relationships with external providers by learning new skills. If the NHS is to benefit from the expertise that external providers have to offer, then wherever possible, knowledge exchange and development of skills within commissioning teams should be components in every contract.
Acknowledgements
T
hanks to all the participants who gave us their accounts, despite considerable time pressures, and oftenallowed observation of their meetings and training events. We are especially grateful to the three external provider organisations and four CCGs that took part. In addition, thanks to the following people: Rachel Anthwal, NHS Fellow at University of Bristol and Programme Manager at South West CSU, for leading on the development and writing-up of actionable messages and commenting on draft reports.
Claire Barry, independent art director, for patiently turning John Gabbay and Andrée le May’s sketches for
Figures 4, 5 and 7–11 into the finished illustrations.
Maya Bimson, formerly of NHS Bristol and United Health Care, for supporting the project since its inception, offering health-care commissioning insight and developing actionable messages for external providers.
Gene Feder, Professor, University of Bristol, for support as and when needed and for reading the final version of the report.
William House, former GP and practice-based commissioner, for supporting the project in its early stages and providing GP commissioning insight.
Andrée le May for attending a mid-project meeting as a‘critical friend’, chairing a cross-case analysis
session, contributing to the figures and commenting on drafts. Tim Wye, Bristol City Council Social Services, for social care insights.
Other commissioners and analysts who participated at various points of the project to provide frontline input and helped to develop actionable messages for commissioners and CSUs included:
Michael Bainbridge, Somerset CCG.
Jude Carey, NHS Fellow at the University of Bristol and Bristol CCG. Neil Riley, South West CSU.
Adwoa Webber, Bristol CCG.