Uncovering the processes of knowledge transformation: the example of local evidence-informed policy-making in United Kingdom healthcare.

BACKGROUND: Healthcare policy-makers are expected to develop 'evidence-based' policies. Yet, studies have consistently shown that, like clinical practitioners, they need to combine many varied kinds of evidence and information derived from divergent sources. Working in the complex environment of healthcare decision-making, they have to rely on forms of (practical, contextual) knowledge quite different from that produced by researchers. It is therefore important to understand how and why they transform research-based evidence into the knowledge they ultimately use. METHODS: We purposively selected four healthcare-commissioning organisations working with external agencies that provided research-based evidence to assist with commissioning; we interviewed a total of 52 people involved in that work. This entailed 92 interviews in total, each lasting 20-60 minutes, including 47 with policy-making commissioners, 36 with staff of external agencies, and 9 with freelance specialists, lay representatives and local-authority professionals. We observed 25 meetings (14 within the commissioning organisations) and reviewed relevant documents. We analysed the data thematically using a constant comparison method with a coding framework and developed structured summaries consisting of 20-50 pages for each case-study site. We iteratively discussed and refined emerging findings, including cross-case analyses, in regular research team meetings with facilitated analysis. Further details of the study and other results have been described elsewhere. RESULTS: The commissioners' role was to assess the available care provision options, develop justifiable arguments for the preferred alternatives, and navigate them through a tortuous decision-making system with often-conflicting internal and external opinion. In a multi-transactional environment characterised by interactive, pressurised, under-determined decisions, this required repeated, contested sensemaking through negotiation of many sources of evidence. Commissioners therefore had to subject research-based knowledge to multiple 'knowledge behaviours'/manipulations as they repeatedly re-interpreted and recrafted the available evidence while carrying out their many roles. Two key 'incorporative processes' underpinned these activities, namely contextualisation of evidence and engagement of stakeholders. We describe five Active Channels of Knowledge Transformation - Interpersonal Relationships, People Placement, Product Deployment, Copy, Adapt and Paste, and Governance and Procedure - that provided the organisational spaces and the mechanisms for commissioners to constantly reshape research-based knowledge while incorporating it into the eventual policies that configured local health services. CONCLUSIONS: Our new insights into the ways in which policy-makers and practitioners inevitably transform research-based knowledge, rather than simply translate it, could foster more realistic and productive expectations for the conduct and evaluation of research-informed healthcare provision.

Evidence based policy making and the 'art' of commissioning - how English healthcare commissioners access and use information and academic research in 'real life' decision-making: an empirical qualitative study.

BACKGROUND: Policymakers such as English healthcare commissioners are encouraged to adopt 'evidence-based policy-making', with 'evidence' defined by researchers as academic research. To learn how academic research can influence policy, researchers need to know more about commissioning, commissioners' information seeking behaviour and the role of research in their decisions. METHODS: In case studies of four commissioning organisations, we interviewed 52 people including clinical and managerial commissioners, observed 14 commissioning meetings and collected documentation e.g. meeting minutes and reports. Using constant comparison, data were coded, summarised and analysed to facilitate cross case comparison. RESULTS: The 'art of commissioning' entails juggling competing agendas, priorities, power relationships, demands and personal inclinations to build a persuasive, compelling case. Policymakers sought information to identify options, navigate ways through, justify decisions and convince others to approve and/or follow the suggested course. 'Evidence-based policy-making' usually meant pragmatic selection of 'evidence' such as best practice guidance, clinicians' and users' views of services and innovations from elsewhere. Inconclusive or negative research was unhelpful in developing policymaking plans and did not inform disinvestment decisions. Information was exchanged through conversations and stories, which were fast, flexible and suited the rapidly changing world of policymaking. Local data often trumped national or research-based evidence. Local evaluations were more useful than academic research. DISCUSSION: Commissioners are highly pragmatic and will only use information that helps them create a compelling case for action.Therefore, researchers need to start producing more useful information. CONCLUSIONS: To influence policymakers' decisions, researchers need to 1) learn more about local policymakers' priorities 2) develop relationships of mutual benefit 3) use verbal instead of writtencommunication 4) work with intermediaries such as public health consultants and 5) co-produce local evaluations.

Health technology assessment in India: the potential for improved healthcare decision-making.

Health technology assessment (HTA) is a multidisciplinary approach that uses clinical effectiveness, cost-effectiveness, policy and ethical perspectives to provide evidence upon which rational decisions on the use of health technologies can be made. It can be used for a single stand-alone technology (e.g. a drug, a device), complex interventions (e.g. a rehabilitation service) and can also be applied to individual patient care and to public health. It is a tool for enabling the assessment and comparison of health technologies using the same metric of cost-effectiveness. This process benefits the patient, the health service, the healthcare payer and the technology producer as only technologies that are considered cost-effective are promoted for widespread use. This leads to greater use of effective technologies and greater health gain. The decision-making process in healthcare in India is complex owing to multiplicity of organizations with overlapping mandates. Often the decision-making is not evidence-based and there is no mechanism of bridging the gap between evidence and policy. Elsewhere, HTA is a frequently used tool in informing policy decisions in both resource-rich and resource-poor countries. Despite national organizations producing large volumes of research and clinical guidelines, India has not yet introduced a formal HTA programme. The incremental growth in healthcare products, services, innovation in affordable medical devices and a move towards universal healthcare, needs to be underpinned with an evidencebase which focuses on effectiveness, safety, affordability and acceptability to maximize the benefits that can be gained with a limited healthcare budget. Establishing HTA as a formal process in India, independent of healthcare providers, funders and technology producers, together with a framework for linking HTA to policy-making, would help ensure that the population gets better access to appropriate healthcare in the future.

Corrigendum to "Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis" [Int J Nurs Sci 9/4 (2022) 411-421].

[This corrects the article DOI: 10.1016/j.ijnss.2022.08.003.].

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

BACKGROUND: Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects. STUDY DESIGN: We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically. RESULTS: Six overarching 'Socio-Organisational Functional and Facilitative Tasks' (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills. CONCLUSION: Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis.

Objectives: To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care. Methods: We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles. Results: Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework. Conclusions: Social movement action can provide a lens through which we view implementation science. Collective action and collective identity - concepts less frequently canvassed in implementation science literature - can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

No magic targets! Changing clinical practice to become more evidence based.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part? This article first appeared in Health Care Management Review, 27(3), 35-47.

A multidimensional conceptual framework for analysing public involvement in health services research.

OBJECTIVE: To describe the development of a multidimensional conceptual framework capable of drawing out the implications for policy and practice of what is known about public involvement in research agenda setting. BACKGROUND: Public involvement in research is growing in western and developing countries. There is a need to learn from collective experience and a diverse literature of research, policy documents and reflective reports. METHODS: Systematic searches of research literature, policy and lay networks identified reports of public involvement in research agenda setting. Framework analysis, previously described for primary research, was used to develop the framework, which was then applied to reports of public involvement in order to analyse and compare these. FINDINGS: The conceptual framework takes into account the people involved; the people initiating the involvement; the degree of public involvement; the forum for exchange; and methods used for decision making. It also considers context (in terms of the research focus and the historical, geographical or institutional setting), and theoretical basis. CONCLUSIONS: The framework facilitates learning across diverse experiences, whether reported in policy documents, reflections or formal research, to generate a policy- and practice-relevant overview. A further advantage is that it identifies gaps in the literature which need to be filled in order to inform future research about public involvement.

Discourses of joint commissioning.

Increasing attention has focused on the role of joint commissioning in health and social care policy and practice in England. This paper provides an empirical examination of the three discourses of joint commissioning developed from an interpretative analysis of documents by Dickinson et al. (2013; BMC Health Services Research, 13) and applied to data from our study exploring the role of knowledge in commissioning in England. Based on interviews with 92 participants undertaken between 2011 and 2013, our analysis confirms that the three discourses of prevention or empowerment or efficiency are used by professionals from across health and social care organisations to frame their experiences of joint commissioning. However, contrary to Dickinson et al., we also demonstrate that commissioners and other stakeholders combine and trade off these different discourses in unexpected ways. Moreover, at sites where the service user experience was central to the commissioning process (joint commissioning as empowerment), a greater sense of agreement about commissioning decisions appeared to have been established even when the other discourses were also in play.

Qualitative study of depression management in primary care: GP and patient goals, and the value of listening.

BACKGROUND: Guidelines for depression management have been developed but little is known about GP and patient goals, which are likely to influence treatment offers, uptake, and adherence. AIM: To identify issues of importance to GPs, patients, and patients' supporters regarding depression management. GP and patient goals for depression management became a focus of the study. DESIGN OF STUDY: Grounded theory-based qualitative study. SETTING: GPs were drawn from 28 practices. The majority of patients and supporters were recruited from 10 of these practices. METHOD: Sixty-one patients (28 depressed, 18 previously depressed, 15 never depressed), 18 supporters, and 32 GPs were interviewed. RESULTS: GPs described encouraging patients to view depression as separate from the self and 'normal' sadness. Patients and supporters often questioned such boundaries, rejecting the notion of a medical cure and emphasising self-management. The majority of participants who were considering depression-management strategies wanted to 'get out' of their depression. However, a quarter did not see this as immediately relevant or achievable. They focused on getting by from day to day, which had the potential to clash with GP priorities. GP frustration and uncertainty could occur when depression was resistant to cure. Participants identified the importance of GPs listening to patients, but often felt that this did not happen. CONCLUSION: Physicians need greater awareness of the extent to which their goals for the management of depression are perceived as relevant or achievable by patients. Future research should explore methods of negotiating agreed strategies for management.

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange.

OBJECTIVES: The use of external consultants from private and not-for-profit providers in the National Health Service (NHS) is intended to improve the quality of commissioning. The aim of this study was to learn about the support offered to healthcare commissioners, how external consultants and their clients work together and the perceived impact on the quality of commissioning. SETTING: NHS commissioning organisations and private and not-for-profit providers. DESIGN: Mixed methods case study of eight cases. DATA COLLECTION: 92 interviews with external consultants (n=36), their clients (n=47) and others (n=9). Observation of 25 training events and meetings. Documentation, for example, meeting minutes and reports. ANALYSIS: Constant comparison. Data were coded, summarised and analysed by the research team with a coding framework to facilitate cross-case comparison. RESULTS: In the four contracts presented here, external providers offered technical solutions (eg, software tools), outsourcing and expertise including project management, data interpretation and brokering relationships with experts. In assessing perceived impact on quality of commissioning, two contracts had limited value, one had short-term benefits and one provided short and longer term benefits. Contracts with commissioners actively learning, embedding and applying new skills were more valued. Other elements of success were: (1) addressing clearly agreed problems of relevance to managerial and operational staff (2) solutions co-produced at all organisational levels (3) external consultants working directly with clients to interpret data outputs to inform locally contextualised commissioning strategies. Without explicit knowledge exchange strategies, outsourcing commissioning to external providers resulted in the NHS clients becoming dependent. CONCLUSIONS: NHS commissioning will be disadvantaged if commissioners both fail to learn in the short term from the knowledge of external providers and in the longer term lose local skills. Knowledge exchange mechanisms are a vital component of commissioning and should be embedded in external provider contracts.

Clinical- and cost-effectiveness of pegylated interferon alfa in the treatment of chronic hepatitis C: a systematic review and economic evaluation.

OBJECTIVES: To assess the clinical-effectiveness and cost-effectiveness of pegylated interferon alfa (2a and 2b) combined with ribavirin in previously untreated patients with moderate to severe chronic hepatitis C, compared with the current standard treatment, which is nonpegylated interferon alfa combined with ribavirin. METHODS: Systematic review and economic evaluation. A sensitive search strategy was applied to several electronic bibliographic databases. Relevant studies were critically appraised and meta-analyzed. A hypothetical cohort of 1,000 patients entered a Markov model and were followed up for a more than 30-year period to predict natural history, duration spent in each health state, and treatment costs. RESULTS: Two fully published Phase III randomized controlled trials were included. Methodological quality was generally good. Dual therapy with pegylated interferon was significantly more effective than nonpegylated dual therapy with a pooled sustained virological response rate (SVR) of 55 percent (95 percent confidence interval [CI], 52-58 percent) compared with 46 percent (95 percent CI, 43-49 percent). The pooled relative risk of remaining infected was 0.83 (95 percent CI, 0.76-0.91 percent). Genotype was the strongest predictor of outcome, with SVRs in patients with the more responsive genotypes 2 and 3 reaching up to 80 percent. The incremental cost per quality-adjusted life year (QALY) for pegylated dual therapy compared with nonpegylated dual therapy was 12,123 pounds sterling. The cost per QALY remained under 30,000 pounds sterling for most patient subgroups and in sensitivity analyses. CONCLUSIONS: Pegylated interferon is clinically effective, represents good value for the money, and is a significant advance in the treatment of this insidious disease.

Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care.

OBJECTIVE: To explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions. DESIGN: Ethnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically. SETTING: Two general practices, one in the south of England and the other in the north of England. PARTICIPANTS: Nine doctors, three nurses, one phlebotomist, and associated medical staff in one practice provided the initial data; the emerging model was checked for transferability with general practitioners in the second practice. RESULTS: Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on "mindlines"--collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues' experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid "communities of practice," resulting in socially constructed "knowledge in practice." CONCLUSIONS: These findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.

No magic targets! Changing clinical practice to become more evidence based.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part?

HTA education and training in Europe.

OBJECTIVE: To identify training programs and educational resources in health technology assessment (HTA) in Europe. METHODS: A postal survey among potential informants in European countries and Israel, expanding on surveys among ISTAHC and INAHTA members. Informants were identified either using HTA networks or by means of Internet sources. RESULTS: The combined results of the three surveys show that in the European Union (EU), including Norway and Switzerland, 13 of 17 countries (76%) provide either university level courses or continuing education HTA courses. In the candidate EU countries, 4 of 10 countries (40%) provide HTA courses. In the remainder of countries, only Israel provides HTA courses. Ten different types of courses were identified, mainly applying traditional teaching methods. A substantial number of the courses were first organized in recent years. Many countries in central and eastern Europe expressed the wish to become more involved in HTA. CONCLUSION: There is a rapid increase in the number and diversity of courses in HTA in Europe. In particular, countries in the EU are well represented. Education and training in HTA is scarce in EU candidate membership countries, and virtually absent in the remainder of countries. In general, HTA as a field is in the process of becoming established and institutionalized both in individual countries and internationally. To stimulate this development in the area of education and training, both bilateral cooperation and an EU-wide coordinated effort are recommended.