A strategic approach to promote research among CCGs

The Health and Social Care Act 2012 creates a statutory duty for clinical commissioning groups to “promote research and innovation and the use of research evidence”.

Beyond this statement, national guidance on how CCGs actually promote research, and who is responsible for what in the new NHS landscape, has been thin on the ground.

‘Despite the challenges, there was a consensus that promoting research and innovation was an important priority’

In the spirit of “liberating the NHS” from central control and diktats, the Department of Health has left it to individual CCGs to work out what a strategic approach to research and evaluation might look like. This “hands off” approach brings with it the potential benefits of locally responsive solutions but the danger of fragmentation and variation.

As a first step to developing its strategy for research and evaluation, Tower Hamlets Clinical Commissioning Group commissioned a small scoping exercise in early 2013. This brought together the views of local stakeholders and others involved with the strategic development of primary care research.

‘Growing a culture of research is more about changing hearts and minds than developing a document with the “research strategy” written on it’

The brief was to explore stakeholders’ views about how best to build a culture of research, and for the CCG to use the findings to develop a locally owned and evidence based strategy and plan for action. Although a local exercise, the broad findings are considered applicable to other groups.

Set against competing demands, many CCG member respondents in our study thought that getting involved in research was likely to be low priority, perhaps even pie in the sky. A recent report from the Association of Medical Research Charities found that while the majority of GPs thought research was important, less than a quarter felt they should be involved personally, giving some indication of the size of the challenge CCGs face.

However, despite the challenges, there was a consensus that promoting research and innovation was an important priority. And there are processes CCGs can put in place to achieve this.

Building and sustaining a research culture

We identified four critical components to building and sustaining a culture of research:

• leadership;
• partnerships;
• use of evidence; and
• professional education and development.

They all involve long term planning and one of the clear lessons from our study is that anyone looking for quick fixes is likely to be disappointed. Growing a culture of research is more about changing hearts and minds and capacity building rather than simply developing a document with “research strategy” written on it.

Strong leadership at all levels from the CCG board to research champions in individual practices and provider organisations was seen as essential in promoting research as a “win-win situation”.  

‘Developing better links with local academic researchers should be a top priority for CCGs’

Demonstrating how high quality research can lead to better care for patients, professional satisfaction for clinicians (as well as contributing to revalidation requirements), better use of local resources, and defensible commissioning decisions were also important. Leadership needs to give a steer that research is about more than biomedical studies and give equal weight to the value of health services and organisational research.

Our respondents were clear that CCGs can only be effective in promoting research by developing strong partnerships. Compared with primary care trusts, CCGs are “very cut down” organisations.

Making links

Additionally, CCGs are not academic organisations. This means that in most circumstances they need to focus on supporting, enabling and coordinating others to engage in research activity, rather than leading and undertaking research themselves.

Developing better links with local academic researchers should be a top priority for CCGs. Even in an area such as Tower Hamlets, which has a good track record of such links (eg: the pioneering work of the clinical effectiveness group at St Bartholomew’s Hospital and the London School of Medicine and Dentistry), stakeholders thought there was considerable scope for improvement.  

Practical suggestions included more outreach work with local practitioners by academics involved in the National Institute for Health Research’s Research Design Service, honorary appointments, the CCG hosting student research projects and inviting CCG members to academic seminars to encourage an exchange of ideas.

Concern over culture

Some concern was expressed that the current culture in academic departments towards the “big science stuff” of large scale biomedical research rather than more locally relevant, applied research could result in neglect of making “grassroots” links with the local health economy and community. 

For example, a recent bid for CLARHC funding was identified by some as being about promoting research locally, in theory, but in practice driven not so much by primary care service needs and genuine local engagement as by the aspirations and priorities of academic biomedical scientists.

Overall, there was concern that the detail of where and with who various research roles and responsibilities lay − for example, for research governance, setting local research policy, hosting local research networks − was unclear. 

‘Maintaining and building partnerships with local voluntary organisations is vital to ensuring patient involvement in developing research plans’

There was particular uncertainty about what implications the transfer of the public health function to the more politicised environment of local authorities will have on the setting of research priorities.

Respondents stressed that maintaining and building partnerships with local voluntary organisations is vital to ensuring patient and public involvement in developing research plans, and making sure that research is genuinely responsive to the health needs of local communities. 

Partnerships will only ever be as good as the individuals that comprise them. While effective partnership working requires certain structures to be in place, structures on their own will not necessarily result in productive partnerships. 

Important lessons

At the root of all research activity is evidence. We identified a number of important lessons for CCGs as they grapple with how to ensure they use evidence based commissioning. Commissioners must specify clearly the research questions to which the local health economy needs answers. 

They must work with local providers to ensure the quality of their routine data is high, and that their systems for recording activity are also serviceable for research and evaluation purposes.

They must insist that evaluation is an integral part of any service development and that evaluation findings are fed into the commissioning cycle. They need to demonstrate how commissioning decisions, especially those involving disinvestment and decommissioning, have been based on best available evidence. 

CCGs must take a broad perspective on what constitutes evidence, for example by incorporating evidence from large datasets of routinely collected information, such as clinical trial data, organisational and health services research, evaluation of services and service innovations, needs assessments, public health and epidemiology data, and, importantly, qualitative data including patient experience, patient narratives and other community intelligence.

Two sides to the story

Some respondents were excited by what they described as the “to die for” opportunities that IT developments offered in terms of providing evidence from large datasets of routinely collected “real time” data. As an example, these datasets could allow easy identification of the number of specific investigations undertaken by individual practices, facilitating evidence based commissioning decisions.

‘There is a need to increase the understanding of patients and the public about research and how they can support it and contribute’

Others, however, were more sceptical of the vision of a health service that is fully networked, electronically integrated, with centralised data warehouses generating information to provide limitless opportunities for research and evaluation. This vision was criticised both for its focus on the collection of data as an end in itself and its ethical naivety, failing to address critical questions about purpose, control and ownership. 

Concerns were expressed about the proposed long term direction to privatise the commissioning support units hosting data warehouses. It is important CCGs stay alert to, and reflect upon, the potential benefits and risks of developments in local information systems.

They should ensure an education and training strategy supports their research and evaluation strategy. The two are closely related in that there is an identified need for enhancing an understanding about research, and the skills required to conduct or apply it in the CCG context, at all levels in the organisation and in constituent practices. There is also a need to increase the understanding of patients and the public about research and how they can support it and contribute. 

Practical suggestions for professional development activities that CCGs could promote include:

• production of a “research made easy” guide, explaining the broad scope of research and evaluation as relevant to GPs and the CCG;
• induction programmes to include information on how employees can contribute to the CCG’s commitment to research, innovation and evaluation;
• masterclasses for board members; and
• working with CCG patient and public involvement leads to educate, empower and involve patients and the public in research and evaluation.

Since commissioning the scoping exercise, Tower Hamlets CCG has produced a three year implementation plan based on the four components to building and sustaining a culture. CCGs seeking further guidance to help them develop their research and evaluation strategies are directed to the Research, Evidence and Innovation Self-assessment Framework for CCGs and NHS Commissioning Board Local Area Teams, and a vision for research in the NHS published by the Association of Medical Research Charities.

Jill Russell is senior lecturer in health policy and evaluation at Queen Mary University of London, Ros Levenson is an independent researcher, Dr Victoria Tzortziou Brown is a GP and planned care and research lead at Tower Hamlets CCG, and John Wardell is deputy chief officer at Tower Hamlets CCG