Title: Improving the capabilities of NHS organisations to use evidence: A Process Model
Funder: Department of Health (England)

Abstract: Innovation driven by authoritative evidence – that is synthesis of evidence made and published by (albeit not exclusively) the National Institute of Health and Care Excellence (NICE) – is a current and future priority for the NHS (DOH 2010 2011). This is reflected in the UK government’s intentions to set up the “NICE Implementation Collaborative” as well as in significant on-going investment into programmes and centres (such as the Centres for Leadership in Applied Health Research and Care – CLAHRCs) aimed at understanding and improving the translation of new knowledge into practice. Multiple evidence-based products and recommendations for improvements in service delivery (e.g. clinical guidelines) are also increasingly being supplied to NHS organisations and to commissioning bodies in particular to assist them in making decisions. Yet it is quite clear that uptake is patchy and that supply of authoritative evidence does not always connect closely to demand (Crilly et al. 2010a; Dopson et al. 2002). Thus the major challenge for NHS commissioning groups is to proactively and strategically consider how their organisations can be better equipped to make use of evidence in their decisions – a challenge set against significant changes in the commissioning landscape. Of relevance to this challenge are findings from a recent rich stream of research including our own that has studied the mobilisation and use of knowledge and evidence in different organisations and settings in the National Health Service (NHS) (Arndt and Bigelow 2009; Contandriopoulos et al. 2010; Crilly et al. 2010a; Dobrow et al. 2004; Dopson and Fitzgerald 2005; Dopson et al. 2002; Dopson et al. 2003; Gabbay and le May 2004 2010; Gkeredakis et al. 2011). This research has helped to highlight and explain processes (social and political) and dynamics of evidence-based decision making in healthcare and the reasons why innovation so often fails to diffuse (Ferlie et al. 2005). Gabbay and Le May’s (Gabbay and May 2004) study for instance found that when observed in detail the actual use and mobilisation of evidence by GPs is locally and socially conditioned and looks very different from that depicted by more abstract evidence-based guidelines. Rather clinicians rely on ‘mindlines’ socially constructed forms of shared expertise that incorporate evidence derived from a variety of sources in a form that is compatible with their daily activity (Gabbay and Le May 2010). According to Ferlie et al (2010) the key challenge for knowledge mobilisation in NHS organisations lies in “building high learning capacity and appropriate core competencies in NHS organisations rather than relying on a technological fix…” (Crilly et al. 2010b p. 229). While much has been learnt about the fluid and unpredictable ways in which evidence diffuses in NHS organisations (and into commissioning groups) further work is needed to identify and articulate how NHS organisations might develop and improve their capabilities to use evidence more effectively. What constitutes ‘high learning capacity and appropriate core competencies’ and how can these be developed? More needs to be known about how the ‘journey’ of evidence into healthcare commissioning organisations can actually be improved (Greenhalgh et al. 2004). This gap in knowledge is also reflected in senior decision makers’ concern that a “methodology for using evidence” is still elusive (David Stout HSJ 13th May 2010). What is required is a more focused research approach which builds upon the rich understandings of innovation and knowledge transfer generated by previous research but which delivers realistic opportunities for improving capabilities for evidence uptake. Accordingly this research will adopt a comparative research strategy to investigate how the capability of the newly established NHS commissioning organisations – Clinical commissioning groups (CCGs) – to use authoritative evidence can be enhanced. Specifically the research aims to identify the organisational and managerial capabilities that CCGs need to develop in order to improve their capacity to mobilise authoritative evidence. We focus on NICE evidence given its importance to health and social care reforms Through multiple case studies in 8 NHS organisations (CCGs) we will describe systematically the journeys of the same type of evidence used by CCGs in order to explain how variation occurs and under what organisational conditions. The research will develop specific recommendations for capability enhancement by explaining comprehensively how more successful journeys differ from less successful ones and the processes and capabilities that may need to be in place. Furthermore the focus will be on two kinds of authoritative evidence aimed at innovation in service delivery: (A) evidence that orients healthcare organisations toward adopting service quality enhancements (e.g. new NICE guidelines/guidance for achieving improved higher standards of care etc.); (B) evidence that orients healthcare organisations towards abandoning outmoded practices (e.g. disinvestment guides recommending complex even tough decommissioning decisions). These are chosen because both are essential to deliver innovation in the NHS but they may pose distinctive challenges. For example pathway change usually means learning to improve existing modes of delivery whereas disinvestment means jettisoning outmoded practices or ‘unlearning’. Research suggests that the dimensions underpinning learning and unlearning in organisations and the capabilities required may be quite different (Fiol 2012; Tsang and Zahra 2008). Moreover unlearning has received scant attention either in theory or in practice. The key objectives of our comparative approach then are first to observe and document meticulously how authoritative evidence actually travels in practice into the decisions of CCGs; and second to identify the capabilities (practices and enabling conditions) that make the journey and organisational processing of evidence more effective. We will synthesise our findings by developing a process-based model that explains how and why the travel of evidence becomes more or less effective in practice on the basis of common outcome measures. The intended outcome is to provide NHS decision makers in CCGs with a set of practical improvement methods - a process ‘roadmap’ and associated diagnostic/benchmarking tool – which will enable them to assess their organisations’ capabilities to use different types of evidence and identify opportunities for improvement. These will map the route to effective evidence use and take due account of both organisational dynamics/complexities and the objectives (purpose) of the decision (i.e. service enhancement and/or disinvestment). These outputs will be created via close engagement with NHS practitioners and with a multi-stakeholder advisory panel who will advise on all stages of the research.ReferencesArndt M. B. Bigelow. 2009. Evidence-based management in health care organizations: A cautionary note. Health Care Manage. Rev. 34(3) 206-213.Contandriopoulos D. M. Lemire J.L. Denis E. Tremblay. 2010. Knowledge Exchange Processes in Organizations and Policy Arenas: A Narrative Systematic Review of the Literature. Milbank Quarterly 88(4) 444-483.Crilly T. A. Jashapara E. Ferlie. 2010a. Research Utilisation & Knowledge Mobilisation. A Scoping Review of the Literature. London: Department of Management King’s College London.Crilly T. A. Jashapara E. Ferlie. 2010b. 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Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE