10 evidence-based ways the GP Clinical Evidence Fellows are making an impact

Ceilidh Jackson – Baker, Project Support Officer with the commissioning evidence-informed care team celebrates the triumphs of our GP Clinical Evidence Fellows…

In June 2017 I helped to organise an event to showcase the achievements of our GP Clinical Evidence Fellows. My team (commissioning evidence-informed care) support the ten Fellows to learn how to access and use evidence and then work with each of our seven clinical commissioning groups (CCGs) to embed this best practice into commissioning decision-making.

What really stood out for me at the showcase was the level of impact the Clinical Evidence Fellows are already achieving across a whole range of different areas. The feedback from attendees showed that CCGs also recognise their value.

Attending the GP Clinical Evidence Fellows’ event on the 13 June 2017 was really inspirational. The short presentations each GP Fellow gave highlighted the personal and professional journeys they had been on and how their knowledge of the commissioning world had increased. With clinical commissioning groups looking for evidence to inform the commissioning decisions, Clinical Evidence Fellows have a lot to offer.

Becca Robinson, Service Improvement Lead – Bristol Clinical Commissioning Group

Here, in no particular order, are my top ten ways our Clinical Evidence Fellows are influencing commissioning in the West of England:

  1. Improving interventions for frail elderly people

Dr Bisola Ezobi’s work looking into evidence on community-based interventions for frail elderly people for Bath & North East Somerset CCG has resulted in Comprehensive Geriatric Assessments being implemented in the community.

  1. Evidence reviews for clinical policies

Dr Catherine Bennett’s evidence searches relating to clinical policies have been used to guide the formal policy review and redesign at Wiltshire CCG to ensure that evidence underlies their decision-making.

We need to continue to support the Fellows and embed them into CCG life!” Wiltshire CCG representative

  1. Minor procedures demand management

Swindon CCG have moved most minor surgical procedures to the same evidence-based criteria as Wiltshire CCG as a result of Dr Francis Campbell’s work, thus reducing inequality of access to these services to the local populations.

  1. Near-Patient CRP testing

Dr Caroline Ward implemented a pilot study of near patient C-reactive protein (CRP) testing with the Urgent Care Unit in Swindon CCG. This is a simple pinprick blood test taken in the consultation which gives results in minutes as to whether a patient has an infection that needs antibiotics. Early results indicate that this has reduced unnecessary antibiotic prescribing, which is good for antimicrobial resistance – and therefore patient care and CCG prescribing budgets.

  1. Expert Patient Programme

Dr Vanessa Dane’s review of the available evidence for peer led self-management programmes was presented to the Gloucestershire CCG clinical programme teams who used the findings to inform development of the Expert Patient Programme.

The GP Clinical Evidence Fellowship is “a great initiative and I will continue to support and endorse the importance of evidence-based commissioning.” Gloucestershire CCG representative

  1. Supporting improvement of the COPD pathway

Dr Farida Ahmad has helped to increase awareness across Bristol, North Somerset and South Gloucestershire STP of the evidence that pulmonary rehab can make a positive difference for people with Chronic Obstructive Pulmonary Disease (COPD).

For a relatively small amount of time and money a huge amount has been achieved professionally and personally and in CCG benefit.” Bristol CCG representative

  1. Reviewing the use of digital apps in the treatment of depression

Dr Ed Mann’s review of the use of digital apps in the treatment of depression saved North Somerset CCG money through not investing in iCBT due to there being no strong evidence supporting its effectiveness.

Dr Mann’s evidence review “looked at specific models (and the evidence behind them) currently available on the market. It also pulled in the current commissioning context and demonstrated a knowledge of the current pathway and therefore opportunities to transform. It then weighed up the pros/cons.” North Somerset CCG representative

  1. Informing service change through effective use of RightCare data

RightCare is a programme for identifying unwarranted variation in health across CCGs. The RightCare data reports produced by Dr Charlie Kenward have been shared with various teams across North Somerset CCG and are informing service change. This has included transformation teams discussing the need to develop an evidence-based plan for relieving pressure on A&E.

  1. Reviewing injection therapy for treating low back pain

Dr Nick Snelling’s evidence review on treating low back pain with injection therapy has resulted in facet joint injections only being available by exception as the evidence suggests insufficient clinical effectiveness for offering these routinely. This means anticipated savings across Bristol, North Somerset and South Gloucestershire STP of approximately £100,000 per year, and alternative pathways to manage patients’ pain in the long-term.

  1. Suicide prevention in the LGBTQ community

Dr Phil Simons completed an evidence review on suicide prevention strategies for the LGBTQ community as part of the South Gloucestershire Suicide Prevention Strategy and made various recommendations for improving support and training, particularly in schools, which the partnership group are looking to implement.

Phil’s work has reinforced the LGBT community as one of our local priority groups for reducing inequalities… His review has helped shape what this might look like in practice, influenced strategy and specifically plans to provide more LGBTQ support in schools.” Public Health Programme Lead (Mental Health & Emotional Well Being) for South Gloucestershire Council

Find out more

the opportunity to network and discuss our roles provided a valuable opportunity for inter professional knowledge exchange…The morning was informative, well organised and personally motivating for me and was useful not only in my new role with APCRC, but also for clinical and teaching purposes. In conclusion, a great morning and time very well spent!

Dr Anne Johnson, Senior Lecturer/Researcher in Residence Fellow – Avon Primary Care Research Collaborative

Evidence Live 2017 – the Glastonbury of evidence-based medicine

Our Primary Care Programme Lead, Sian Jones shares her thoughts on this year’s Evidence Live…

20 June 2017 was one of the hottest evenings since the summer of 1976 to be heading to Oxford for the evidence nerd-fest that is Evidence Live. This two day international conference brings together the great and the good of evidence-based medicine (EBM), geeks and gawping groupies, as well as a lot of us who want to expand our knowledge and networks, or share what we’re doing.

Oxford University’s Centre for Evidence-Based Medicine (CEBM) and the British Medical Journal (BMJ) jointly run this event every year. Ben Goldacre of ‘Bad Pharma’ and ‘Bad Science’ fame, refers to the conference as “the Glastonbury of EBM”, where “everyone who is anyone passes through”.

Bristol on tour

This year I attended just one day to support Bristol colleagues presenting from CLAHRC West and UWE. We gathered in the stylish Blavatnik School for Government where the conference started with an opening address from Fiona Godlee, BMJ Editor-in-Chief.

To give a sense of day one, the plenaries covered:

  • Fergal O’Regan from the European Ombudsman on transparency of clinical trials data from the viewpoint of the European Medicines Agency.
  • Doug Altman; Oxford Professor of Statistics in Research, on the scandal of poor medical research. He explained that nothing much has changed over more than 20 years and says “ignorance of research methods is no excuse, if you can’t do it well, don’t do it”.
  • A thought provoking presentation from Mary Dixon-Woods; Cambridge Professor of Health Services Research, on improving evidence for improving healthcare, where many examples were presented to show how the evidence that quality improvement (QI) improves quality is not robust and evaluation is lacking. She shared the good news that Cambridge University has been awarded a grant from The Health Foundation to set up an Improvement Research Institute to strengthen the evidence base for improvement and she will be leading this.

Evidence-based medicine versus evidence-informed commissioning

A key focus of the conference was a consultation on the EBM Manifesto for Better Healthcare. This has been developed with the aim of finding solutions for better healthcare evidence, in response to the 2014 BMJ paper by Trisha Greenhalgh et al ‘Evidence based medicine: a movement in crisis’. The Manifesto is concerned with the increasing volume of evidence that is of variable quality and how this impacts decision making.

Simply put, bad (untrustworthy) evidence results in poor decisions. This clearly has implications for patient care. So the EBM Manifesto hopes to fix the problems in EBM asking for ideas from stakeholders via the ongoing consultation.

EBM has been around for over 20 years and has been adopted as an approach to support clinical decision making. I was reflecting on the view of the EBM leaders that EBM is in crisis, and thinking about commissioning – the area of healthcare we are working to influence at the West of England AHSN.

Commissioners are responsible for two-thirds of the NHS budget, yet the way they make decisions on how to allocate this has not been formally studied and there has not been an approach like EBM devised to support them. We also don’t suffer from too much research, whereas in EBM – the reverse is true. The Health and Social Care Act 2012 makes reference to the need for greater participation by Clinical Commissioning Groups (CCGs) in research, but before this there has been little requirement on commissioning organisations to apply research evidence.

Commissioners make decisions that affect populations: it’s a big deal! So it feels like commissioning is in an even worse place than EBM. It is not an issue of not wanting to use research, but it’s not always easy.

Our very own manifesto

Despite the heat, Evidence Live 2017 was a less nervy experience than 2016 when I co-presented a workshop on evidence-informed commissioning with Alison Turner from Midlands and Lancashire Commissioning Support Unit. The workshop nurtured an idea for a manifesto (yes another one!) for commissioning, setting out ten steps towards an ideal world of evidence-informed commissioning.

This has been blogged about here:

Our manifesto represents a call to action and we would encourage those who have an opportunity to influence commissioning decisions to use it as a set of aspirational standards.

How evidence-informed health can tackle the supply and demand gap

In this blog post, first published in the HSJ, Peter Brindle spells out three ingredients which can ensure that evidence – with all its money-saving potential – is incorporated into NHS practice…

The NHS should stand out as the most evidence-informed health system in the world. The worsening mismatch between the demand on the NHS and its resources of cash and staff mean we can’t afford not to have an evidence-informed approach to our health and care system.

This means making a deliberate and conscious effort to routinely look for and use the best available evidence before spending scarce resources on a new model of care or technology. And when the evidence is incomplete, which is most of the time, we need to commit to creating evidence through evaluating the change.

Having an evidence-informed approach makes sense. From a range of possible service designs, interventions or innovations, we will get better outcomes from those that have evidence of effectiveness compared to those that do not. Better outcomes mean spending less on the consequences of poor ones. Also having the evidence to hand makes it easier to defend stopping doing things that don’t work or that harm people.

“It is still not easy to create a truly evidence-informed system. One of the most potent reasons is the culture gap between the evidence producers and evidence users”

So how do we get the evidence informed approach into practice? The tens of thousands of NHS staff who have some management responsibility are the crucial link between the evidence and the beneficiaries – patients and the public. But while many people know this is the right approach, they find it hard to do. This we have to change and make the right way the easy way. Let’s consider three ingredients to making this happen:

Hardwire into the processes of normal business

Let’s get the paperwork right and make sure that business cases and priority-setting templates have sections asking about a balanced evidence appraisal and how the proposals are to be evaluated – and with what resource? Service specifications also need to be clear from the outset that potential providers must demonstrate an evidence-informed approach. Signing up to these 10 statements to improve decision-making in the commissioning of health services would be an excellent start.

Engage the right people

Leaders should understand that not following an evidence-informed approach is unaffordable and risky. They need to expect the same from their teams, creating the culture that working in an evidence-informed way is everybody’s business.

But even with good leadership and willing teams, it is still not easy to create a truly evidence-informed system. There are many reasons for this, but perhaps one of the most potent is the culture gap between the evidence producers – primarily researchers – and the evidence users who commission and provide services. Researchers might be seen as being out of touch with current service priorities and pressures, and those working in the service are sometimes seen by researchers as having a disregard for their evidence.

There is also reluctance from those on the service side to take responsibility for creating their own evidence through a routine approach to service evaluation – they cannot always expect researchers and academia to produce the kind of evidence they need.

One way of tackling these issues is having people and teams who have a specific role in promoting better evidenced services and more impactful research and who can successfully cross the boundary between the service and research worlds. Some of the approaches we are using in the West of England include:

Health integration teams, which bring together patients, commissioners, providers, researchers and clinicians to tackle specific service related issues and in some cases become the main governance structure for a particular service area.

GP clinical evidence fellows are GPs seconded for one or two sessions per week into CCG leadership position to champion the use of evidence, conduct evidence appraisals and support an evidence informed business planning process. A similar programme has recently been launched in the North West of England.

NHS management fellows are commissioners who are seconded into a university research team and their colleagues, Researchers in Residence, are the reverse – researchers seconded to a CCG commissioning team. Their role is to act as translators between the academic and service environment, bringing their skills and knowledge from one environment to the other, identifying NHS-relevant research questions and promoting the co-production of high impact research.

Resources

Despite having the right leadership and organisational processes guiding staff to work in an evidence-informed way, knowledge and skills are still needed to make the right way the easy way. Training workshops based on practical toolkits can give the confidence to get started and signpost to existing but often under-used resources such as the library and knowledge services, public health, commissioning support units and regional CLAHRCs (Collaboration for Leadership in Applied Health Research and Care).

The challenge

In a world of crushing timelines and the need for in-year savings, how do organisations create the financial and strategic space to develop an evidence informed approach – one that offers few quick fixes but longer term benefits? But then that’s the point: The less money and time there is, the greater the need for a culture that reduces the waste from initiating or continuing ineffective and harmful services and products.

By using just a tiny proportion of the health and care spend in a better evidenced and evaluated way, it would save millions. Now more than ever, there is too much at stake in the NHS to take anything other than an evidence-informed approach. We can’t afford not to.