Evidence-based commissioning in the English NHS : who uses which sources of evidence? A survey 2010/2011

Objectives: To investigate types of evidence used by healthcare commissioners when making decisions and whether decisions were influenced by commissioners’ experience, personal characteristics or role at work. Design: Cross-sectional survey of 345 National Health Service (NHS) staff members. Setting: The study was conducted across 11 English Primary Care Trusts between 2010 and 2011. Participants: A total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey. Main outcome measures: Participants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role. Results: The extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades). Conclusions: Those trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential

Young age as a prognostic factor in cervical cancer: analysis of population based data from 10 022 cases

The effect of young age on survival in cervical cancer is not fully known, although evidence has suggested that it is a poor prognostic factor and that young patients should therefore be treated differently from older patients. All 10 022 cases of invasive cervical cancer in the west Midlands during 1957-81, which comprised 10% of the cases in England and Wales, were analysed to determine the prognostic effect of age. Univariate analysis showed a median survival time of 54 months for all cases, with survival rates at five years of 69% for patients aged under 40 and 45% for those aged 40 or older (χ12 (log rank)=331·4; p<0·0001). This difference remained significant after stratification for stage (χ12 (log rank)=7·1; p=0·008). Cox regression analysis with nine covariables, including age and year of registration, reaffirmed the importance of conventional prognostic factors such as stage of disease, size of tumour, state of lymph nodes, and differentiation of the tumour. After allowance was made for the effects of other prognostic factors young age was found to be a small but significant favourable factor that did not change during the period of the study. Estimated survival distributions obtained from the Cox model showed that for women presenting with the common characteristics associated with stage Ib disease who were treated with radical radiotherapy the survival rate at five years fell non-linearly from 71% in the group aged 25-29 to 65% in the group aged 65-69

Mind the gap : understanding utilisation of evidence and policy in health care management practice

Purpose – The paper aims to take a reflective stance on the relationship between policy/evidence and practice, which, the authors argue, is conceptually under-developed. The paper aims to show that current research perspectives fail to frame evidence and policy in relation to practice. Design/methodology/approach – A qualitative study was conducted in the English NHS in four Primary Care Trusts (PCTs). Seventy-five observations of meetings and 52 semi-structured interviews were completed. The approach to data analysis was to explore and reconstruct narratives of PCT managers' real practices. Findings – The exploratory findings are presented through two kinds of narratives. The first narrative vividly illustrates the significance of the active involvement, skills and creativity of health care practitioners for policy implementation. The second narrative elucidates how problems of collaboration among different experts in PCTs might emerge and affect evidence utilisation in practice. Practical implications – The findings exemplify that policies are made workable in practice and, hence, policy makers may also need to be mindful of practical intricacies and conceive policy implementation as an iterative process. Originality/value – The contribution of this paper lies in offering an alternative and important perspective to the debate of utilisation of policy/evidence in health care management and in advancing existing understanding of health care management practice. The paper's rich empirical examples demonstrate some important dimensions of the complexity of practice