The role of research in helping general practice commission efficient healthcare

Getting the most out of knowledge and innovation transfer agents in health care: a qualitative study

Background

Knowledge and innovation transfer (KIT) is recognised internationally as a complex, dynamic process that is difficult to embed in organisations. There is growing use of health service–academic–industry collaborations in the UK, with knowledge brokers linking producers with the users of knowledge and innovation.

Aim

Focusing on KIT ‘agent’ roles within Academic Health Science Networks in England and Partnerships in Wales, we show how individual dispositions, processes and content contribute to desired outcomes.

Methods

We studied the KIT intentions of all Academic Health Science Networks in England, and the South East Wales Academic Health Science Partnership. Using a qualitative case study design, we studied the work of 13 KIT agents purposively sampled from five networks, by collecting data from observation of meetings, documentation, KIT agent audio-diaries, and semistructured interviews with KIT agents, their line managers and those they supported (‘Links’). We also used a consensus method in a meeting of experts (nominal group technique) to discuss the measurement of outcomes of KIT agent activity.

Findings

The case study KIT agents were predominantly from a clinical background with differing levels of experience and expertise, with the shared aim of improving services and patient care. Although outside of recognised career structures, the flexibility afforded to KIT agents to define their role was an enabler of success. Other helpful factors included (1) time and resources to devote to KIT activity; (2) line manager support and a team to assist in the work; and (3) access and the means to use data for improvement projects. The organisational and political context could be challenging. KIT agents not only tackled local barriers such as siloed working, but also navigated shifting regional and national policies. Board-level support for knowledge mobilisation together with a culture of reflection (listening to front-line staff), openness to challenges and receptivity to research all enabled KIT agents to achieve desired outcomes. Nominal group findings underscored the importance of relating measures to specific intended outcomes. However, the case studies highlighted that few measures were employed by KIT agents and their managers. Using social marketing theory helped to show linkages between processes, outcomes and impact, and drew attention to how KIT agents developed insight into their clients’ needs and tailored work accordingly.

Limitations

Level of KIT agent participation varied; line managers and Links were interviewed only once; and outcomes were self-reported.

Conclusions

Social marketing theory provided a framework for analysing KIT agent activity. The preparatory work KIT agents do in listening, understanding local context and building relationships enabled them to develop ‘insight’ and adapt their ‘offer’ to clients to achieve desired outcomes.

Future work

The complexity of the role and the environment in which it is played out justifies more research on KIT agents. Suggestions include (1) longitudinal study of career pathways; (2) how roles are negotiated within teams and how competing priorities are managed; (3) how success is measured; (4) the place of improvement methodologies within KIT work; (5) the application of social marketing theory to comparative study of similar roles; and (6) patients as KIT agents.

Funding

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

Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers

Background

The health-care commissioning cycle is an increasingly powerful determinant of the health services on offer and the care that patients receive. This study focuses on the mobilisation and use of evidence relating to ethnic diversity and inequality.

Objective

To describe the patterns and determinants of evidence use relating to ethnic diversity and inequality by managers within commissioning work and to identify promising routes for improvement.

Methods

In-depth semistructured interviews with 19 national key informants and documentation of good practice across England. Detailed case studies of three primary care trusts involving 70+ interviews with key strategic and operational actors, extensive observational work and detailed analysis of related documentation. A suite of commissioning resources based on findings across all elements were tested and refined through three national workshops of key stakeholders.

Results

Commissioners often lack clarity on how to access, appraise, weight or synthesise diverse sources of evidence and can limit the transformational shaping of services by a narrow conceptualisation of their role. Attention to evidence on ethnic diversity and inequality is frequently omitted at both national and local levels. Understanding of its importance is problematic and there are gaps in this evidence that create further barriers to its use within the commissioning cycle. Commissioning models provide no reward or sanction for inclusion or omission of evidence on ethnicity and commissioning teams or partners are not representative of minority ethnic populations. Neglect of this dimension within national drivers results in low demand for evidence. This organisational context can promote risk-averse attitudes that maintain the status quo. Pockets of good practice exist but they are largely dependent on individual expertise and commitment and are often not shared. Study findings suggested the need for action at three levels: creating an enabling environment; equipping health-care commissioners; and empowering wider stakeholders. Key enabling factors would be attention to ethnicity within policy drivers; senior-level commitment and resource; a diverse workforce; collaborative partnerships with relevant stakeholders; and the creation of local, regional and national infrastructure.

Limitations

It was harder to identify enablers of effective use of evidence in this area than barriers. Including a case study of an organisation that had achieved greater mainstreaming of the ethnic diversity agenda might have added to our understanding of enabling factors. The study was conducted during a period of fundamental restructuring of NHS commissioning structures. This caused some difficulties in gathering data and it is possible that widespread change and uncertainty may have produced more negative narratives from participants than would otherwise have been the case.

Conclusions

Knowledge mobilisation and utilisation within the commissioning cycle occurs in the context of dynamic interactions between individual agency, organisational context and the wider health-care setting, situated within the UK sociopolitical milieu. Our findings highlight isolated pockets of good practice amidst a general picture of limited organisational engagement, low priority and inadequate skills. Findings indicate the need for specific guidance alongside incentives and resources to support commissioning for a multiethnic population. A more comprehensive infrastructure and, most importantly, greater political will is needed to promote practice that focuses on reducing ethnic health inequalities at all stages of the commissioning cycle.

Funding

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