Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers

Goal

To support the commissioning of health services that better meet the needs of BME patients and thereby help reduce ethnic inequalities in health-care experiences and health outcomes.

Aim

To enhance the critical use of research evidence alongside other forms of knowledge by managers within the PCT commissioning cycle.

Objectives

Research question 1: how does a focus on ethnic diversity and inequality shape the knowledge mobilisation and utilisation process within the health services commissioning context?

• What characteristics of research evidence relating to ethnic diversity and inequality influence how it is received by managers (e.g. source, method, (un)certainty, relevance, concepts/theory)?

• What mental models of ‘how research evidence should be used’ are managers working with?

• To what extent is the accessing and application of information relating to ethnic diversity and inequality part and parcel of broader evidence-gathering exercises for commissioning or rather a distinct exercise?

• What factors prompt managers to seek out research (and other types of evidence) relating to ethnic diversity and inequality (e.g. policy directives, new priorities, external audit, stakeholder inputs, signs of service failure)?

Research question 2: how does organisational context shape the mobilisation and utilisation of knowledge relating to ethnic diversity and inequality?

• How often, and at what stages, do managers apply research evidence relating to ethnic diversity and inequality in their commissioning tasks?

• How are commissioning teams constituted and organised? How does this impact on evidence use?

• Who is seen as holding expertise and insight in relation to ethnic diversity and inequality? Why?

• To what extent do PCT commissioning organisations have explicit models, structures, processes and objectives that support the mobilisation and utilisation of evidence? Do these consider ethnic diversity?

• In what ways does managerial behaviour support and encourage, or deter, the explicit consideration of research evidence relating to ethnic diversity and inequality within commissioning teams?

• In what ways do the available infrastructure and resources support and encourage, or deter, the explicit consideration of evidence relating to ethnic diversity and inequality within commissioning teams?

• How do national, regional and organisational policy priorities inter-relate to shape the mobilisation and utilisation of evidence in this area?

Research question 3: how can individual, team and organisational competencies be effectively enhanced to support the critical use of research evidence for the commissioning of services that better meet the needs of a multiethnic population?

• How competent are managers to (1) identify and access, (2) critically appraise and synthesise and (3) adapt and apply evidence relating to ethnic diversity and inequality?

• What expectations do managers have of, and what problems do they encounter with, the evidence base?

• What individual-level factors facilitate or hinder the mobilisation and utilisation of research evidence in this area (e.g. knowledge/awareness, skills and experience, ‘mental maps’, autonomy, authority, personal biography)?

• What areas of capacity development would likely improve the individual- and team-level competencies required for the mobilisation and utilisation of research evidence relating to ethnic diversity and inequality?

• How does research (and other) evidence relating to ethnic diversity and inequality currently find its way into the commissioning process – through which actors and which routes? How can these be supported?

• Who are the key actors and what are the key organisational settings and processes that present barriers against enhanced mobilisation and utilisation of evidence?

• What factors in the wider societal and broader NHS context must be buffered against, or can be drawn on, to support the routine, critical use of research evidence in commissioning for multiethnic populations?

• What characteristics of the form, content and delivery of interventions in support of enhanced mobilisation and utilisation of research evidence are likely to increase relevance and utility?

Literature review

Before the start of the project an extensive literature review was undertaken to guide the development and methodology of the project. It was important for this to cover not only academic papers and research, but also national policies, guidelines and toolkits relating to commissioning, evidence use and ethnicity. This was updated throughout the project and a RefWorks^® (version 2.0; ProQuest LLC, Ann Arbor, MI, USA) database maintained. Considering the evolving nature of the NHS commissioning infrastructure during the period of this study, the research team also attempted to keep up to date with articles in the media, policy directives and information from colleagues.

Project teams

The project was a collaborative endeavour involving two universities and three PCTs. Each PCT had one mid-level manager assigned to the project as a co-researcher and one senior staff member designated as a champion for the project. The champions and one of the co-researchers were engaged in the development of the initial proposal, identifying the research questions and shaping the study design alongside the academic researchers. The named co-researchers in two of the sites were unable to take up the role on the project, a reflection of NHS restructuring and the long time between proposal development and funding. However, once the project was under way, two new co-researchers were appointed and all three co-researchers subsequently engaged in all aspects of the project work alongside the university researchers, including the national-level work (phases 2 and 4) and local case study work (phase 3) that focused on their own organisations. The champions were also engaged in the project, particularly in one of the sites, although their senior roles necessarily meant that they did not have day-to-day involvement, providing input instead at key junctures of the project.

To assist in the development and delivery of the project, three project teams were created to manage and guide the research. The project management group comprised university researchers and PCT-based co-researchers. This group met regularly to design research tools, co-ordinate data collection, provide updates on emerging themes and findings, complete analysis and produce project outputs. This was also the core operational research team, with most members directly engaged in data generation, analysis and reporting. The research team included individuals identifying as white British, British Pakistani and Pakistani, both male and female, across both the academic and PCT researchers. Team reflections during the course of the project did not reveal any significant concerns regarding the influence of researcher ethnicity on the data generated. We did, however, wonder whether the significance of racism might have been more salient had we had a more ethnically diverse research team.

The project advisory group had a wider strategic role in guiding the development, analysis and outputs of the project and linking the project to relevant developments. The group met three times during the project period. This group was formed of senior academics engaged in health inequality and ethnicity at a national level, as well as senior stakeholders from the partner PCTs and individuals from the NHS and third sector with extensive experience of commissioning and health-care policy.

Finally, a user guidance group was convened, comprising representatives from community organisations and third-sector providers engaged specifically with ethnicity and health. Although the end-users of the project are considered to be commissioning managers and other stakeholders involved in health-care commissioning rather than service users, input from organisations directly involved in representing and providing services for minority ethnic communities was considered important. This helped to ground the project towards improving service delivery and prevent the findings from becoming too abstracted. Organisations and individuals were chosen who had previously been engaged in commissioning and who were able to share experiences from service provider and user perspectives.

Selection of primary care trust study sites

Three PCTs were recruited as partner organisations for the study. The intention was that these organisations would form the sites for the in-depth case study work and engage in the project as full partners – in keeping with our integrated knowledge translation model. 77 The PCTs were therefore chosen on the basis of both theoretical and practical considerations. It was important for the sites to reflect a degree of variation in relation to our topic of focus, but it was also important that the organisations would be active partners, willing to invest staff time and engage in reflection on the study findings and their implications for policy and practice. Sites were therefore chosen across South and West Yorkshire where the research team already had strong ties to practice and where relevant work was already under way. A regional focus was also felt to offer the possibility of useful sharing and learning between PCTs. The sites were chosen to have PCTs covering urban areas with significant but contrasting minority ethnic populations, where it was anticipated that there might be a variety of commissioning activities as well as available data and a range of awareness on ethnicity-specific issues. Sheffield, Leeds and Bradford were chosen as sites that fit these criteria, each with different ethnic demographics and organisational structures for health and social care.

Bradford, with its history of immigration from the Indian subcontinent, has long recognised itself as a multiethnic city, with 36% of its population identifying themselves as belonging to an ethnic group other than the white British majority in the 2011 census. 2 In contrast, Sheffield and Leeds had much smaller minority ethnic populations of around 19% and their public services have only recently started to engage seriously with the needs of these communities. Nevertheless, all three cities have experienced high levels of inward migration in recent years and now have well-established as well as newer minority communities. At the time of the study design, all three PCTs were engaged in achieving WCC targets and engaged in work on meeting the needs of BME groups, and all had staff members who were willing and interested to actively engage in shaping the project.

During the study period, Bradford and Airedale PCT and Leeds PCT clustered to form NHS Airedale, Bradford and Leeds. As this initially had little impact on day-to-day commissioning work, the restructuring did not reduce the amount of relevant work being undertaken. However, it did provide opportunities for co-researchers to contrast and reflect on different organisational practices as their functions and management structures were amalgamated.

Although the PCTs formed the focal point of the research, we also explored partnership working and engaged with other key stakeholders across the three cities, including local authorities and third-sector provider organisations.

NHS restructuring

Between the submission of the project proposal to funders and the commencement of the project in October 2010, the new coalition government released their White Paper81 on the NHS, which became the Health and Social Care Act 201282 in March of that year. During this long period of debate, in which the Bill was substantially redrafted, there was great uncertainty as to how the NHS would be restructured. However, it was clear from an early stage that commissioning structures would change significantly.

Central to this was the abolition of PCTs and the establishment of CCGs led by GPs with support from other clinicians. Although some former PCT staff transferred their employment directly to the new CCGs as commissioning managers, others transferred to separate commissioning support units (CSUs), providing commissioning and contracting support to the CCGs. Meanwhile, the public health function of PCTs was transferred to local authorities. Strategic health authorities were also abolished, with a new national body called the NHS Commissioning Board (NHS CB) established with responsibility for commissioning primary care and specialist health services through a network of local offices. Health and well-being boards (HWBBs) were established as local partnerships bringing together the CCGs, local authority, patient and public representatives and other stakeholders as the primary mechanism for setting local health and well-being strategies (Figure 2).

FIGURE 2.

Simplified representation of role shifts from PCTs to new organisations in post-2010 commissioning structures.

Despite these emerging changes, the project retained its focus on PCTs and continued to pursue the original set of research questions, as it was agreed with the Health Services and Delivery Research programme that they retained relevance and value regardless of how commissioning work might be organised in the new NHS. However, three adjustments were made to our methodology. First, explicit questions were added to the key informant interviews to elicit respondents’ opinions and concerns about how evidence and minority ethnic health would be considered in the new commissioning arrangements. Second, the project team deliberately devoted less time in the case study work to comprehensively documenting existing structures within and across the local organisations, focusing instead on functions and processes that were likely to persist following structural transition. Third, we extended our original plan for phase 2 to include the documentation of a number of ‘good practice’ examples. Fourth, the project team kept up to date with developments and designed the analysis and outputs to reflect the changing structures, aiming to ensure that findings were framed in a way that would be applicable, and provide guidance, to the new commissioning teams.

Ethics and governance

Ethical approval was obtained from Nottingham Research Ethics Committee 2 and specific research permission was gained from each of the PCTs that were the main focus of the study. Standard procedures for ensuring informed consent and protection of research data were maintained. The main area of concern related to the difficulty of ensuring complete anonymity given that the identity of the case study sites would be public knowledge – a common issue in this type of health services research. During consent, participants were given the option to review any use of quotes from their interview before publication, or to express their right to have their contributions attributed to them.

Pilot interviews

Before undertaking the main data collection, as described below, a series of informal pilot interviews (n = 6) were undertaken with experts in the field of health-care policy and/or health inequalities. The interviews were very loosely structured and aimed to generate ideas about how the phase 2 interviews might best be structured, complementing the literature review work. These interviews suggested the need to adopt an open-ended and wide-ranging approach to generation of the main data, rather than focusing too narrowly on issues relating to ethnic diversity and inequality. This was felt to be important for three reasons: first, to allow respondents the opportunity to shape their responses and highlight the issues that they felt to be important, particularly because the pilot interviews suggested (and the later fieldwork confirmed) that many commissioning actors do not have a particular interest or expertise in ethnic equality issues; second, to ensure that any claims made for factors operating in relation to our focus on ethnic diversity and inequality were informed by an understanding of factors that shape (and, importantly, constrain) evidence use and commissioning work more generally; and third, pilot interviews alerted us to the potential danger that our findings and subsequent tools could lack relevance to and credibility for end-users unless they were well grounded in a broader understanding of day-to-day commissioning realities.

National key informant interviews

Interviews with selected informants aimed to collect a broad range of perspectives on key characteristics relating to NHS management, the research evidence base, the PCT commissioning context and the wider sociopolitical setting that facilitate or hamper progress towards evidence utilisation in pursuit of reduced ethnic health inequalities. In-depth qualitative interviews with experts have been used successfully to examine the structure and functioning of health-care policy-making at national levels83 and, specifically, to examine evidence use in health. 84

Good practice examples

During the pilot interviews, concern was expressed that cuts and efficiency savings to the NHS, particularly to PCTs, were leading to reductions in capacity amongst E&D staff and the potential for loss of learning and experience in meeting the needs of minority ethnic health populations. We therefore undertook to select and profile 10 examples of promising practice on how evidence had been used to inform commissioning for specific projects on minority ethnic health. The aim of this strand of work was to capture the expertise and experience of staff involved in overcoming specific barriers in this area and to collect positive examples of how projects had been moved forward to completion. Researchers used interviews with key staff alongside documentary analysis to develop a brief narrative of how each piece of work had been undertaken, and to identify any transferable learning on how evidence on ethnicity might best be used to influence commissioning.

A purposeful sample of examples from different areas of health work was selected following recommendations of good practice from key informant interviews and an open call for suggestions on the minority-ethnic-health JISCMail network (see www.jiscmail.ac.uk/lists/minority-ethnic-health.html). A copy of the good practice guide can be found on the project website (see www.eeic.org.uk/mcs).

Local key informant interviews

In addition to the national-level interviews, a number of key informants were identified and interviewed during phase 2 in each of the three focused case study sites. These interviews generated similar data regarding the wider policy and organisational context of commissioning work and formed an essential first step in the case study work. As such, they provided background information and identified areas that would provide examples of ongoing commissioning work. Engaging with local stakeholders early on during the project also proved very useful for establishing the later phases of the project.

Case studies

To further explore and extend thematic findings from the key informant interview stage, detailed case studies were undertaken over several months to examine commissioning in depth. A case study approach allows for the examination of behaviours and phenomena while explicitly embedding exploration within a specific context. 87 A suite of data collection methods was used, including participant observation, interviews, and documentary analysis to collect data at operational group, individual and strategic levels. In our original protocol we stated the intention to convene formal focus group discussions with commissioning staff. However, in practice this proved difficult as respondents’ work commitments made it difficult to identify extended periods of time when they could come together for the research and consequently they preferred us to piggyback our data generation onto their existing work schedules. This meant that we opted for more observational periods, although we also engaged in some guided group discussions, particularly around emerging findings, allowing for useful respondent validation.

Observational work often adopted an ‘observer as participant’ model88 in which researchers were present in commissioning meetings as part of a team, asking prompting questions and, in some cases, engaging and contributing to discussions when relevant. Participants were regularly reminded of the researcher’s role as a research observer. Individual participant interviews allowed the questioning of commissioning actors away from group settings and provided important background information that was not available from observing operational group meetings. Interpretive documentary analysis89 was employed to identify and synthesise key themes from relevant documents. This analytical approach enabled us to identify different layers of explicit and implicit meaning within these documents and link these to themes from the interviews and observational work. Drawing on the experience of researchers focusing on diversity and equality issues, we sought to ‘follow documents around’90 and tap into both official and private discourses to uncover taken-for-granted ‘rules’ and convoluted pathways of influence. As such, the formal data-generation methods were complemented by many informal opportunities and by regular reflection on the part of PCT co-researchers.

Key informant interviews

An ongoing process of analysis was used involving a coding scheme developed and iteratively adjusted during the first interview period, based on theory-derived topics and concepts from pilot interviews. This analysis schema was piloted and refined by all researchers and PCT-based co-researchers in dedicated workshops used to clarify themes and ensure consistent coding across the sites and researchers (see Appendix 2).

Microsoft Excel and Access were used to organise these codes (around 120 grouped into 10 broader themes) into a practicable framework,91 with summary descriptions and direct quotes extracted and used to populate the codes for each interview. This approach allowed researchers to read a topic-by-topic summary of each interview by reading the framework horizontally, or examine a particular coded theme by reading vertically across all of the interviews to explore commonalities and contrasts.

Coding of transcripts was undertaken by the team member who conducted the interview, with around 20% of transcripts checked by a second member of the team to ensure that themes and codes were being completed consistently. The two researchers with most capacity on the project read the coding for all transcripts. After transcription and coding were completed, team members engaged in a series of analysis workshops to discuss, challenge and refine interpretations.

Case studies

Producing an integrated analysis of the rich data generated through the range of methods used in the diverse case study was challenging both practically and theoretically. Data from the interviews, documentary analyses and observational work were all systematically organised and indexed against the coding framework that was developed for the key informant interviews. Regular analysis sessions were held involving university researchers and PCT co-researchers to engage in the inductive and interpretive identification and testing of emerging themes. Internal briefing documents were prepared and circulated during the generation and refinement of theory to ensure transparent links between data and emerging claims (see Appendix 2 for an illustration of the theme document used to link phase 2 emerging findings to the phase 3 work). In line with the theoretical model described earlier, the overarching approach to the analysis was informed by critical ethnographic perspectives, in that we attempted to synthesise the traditional ethnographic focus on the subjective meanings and beliefs of respondents with the insights gained from a broader structural analysis. 92

Analysis of case study material was first carried out at a ‘within-case’ level. The researcher/co-researcher pairs who had undertaken the bulk of data generation in each site worked together to produce the analysis. Detailed narrative templates were prepared separately for both the strategic- and operational-level case studies conducted at each site, detailing the holistic ‘story’ of each of these case studies. Following this stage, thematic templates were next prepared for each case study. The focus here was on integrating, and triangulating, data across each of the domains of analysis (evidence, individual, team, organisation and wider context) in order to describe the diverse factors that shaped evidence utilisation and to identify any enabling factors that support evidence use. Appendix 2 includes the templates that were used for the operational-level case studies by way of illustration; similar templates were also used systematically for the strategic-level work.

Once templates had been completed for the within-case analyses we moved on to the cross-case analysis. This involved a systematic comparison across the three sites to identify relational and substantive patterns. Cross-case analysis work was initiated through a series of face-to-face team workshops in which a structured process of review and reflection on the case-specific templates was followed. The standard templates encouraged all researchers to interrogate their material against a common analytical framework and allowed team members to readily engage with the claims and supporting materials emerging from all three study sites. Subsequently, draft integrated analysis documents were produced and an iterative process of review and refinement involving all research team members was used to draw the data together across the sites into a more general set of claims and findings.

Research question 1: how does a focus on ethnic diversity and inequality shape the knowledge mobilisation and utilisation process within the health services commissioning context?

• What factors prompt managers to seek out research (and other types of evidence) relating to ethnic diversity and inequality?

• To what extent is the accessing and application of information relating to ethnic diversity and inequality part and parcel of broader evidence-gathering exercises for commissioning or rather a distinct exercise?

• What characteristics of research evidence relating to ethnic diversity and inequality influence how it is received by managers?

Research question 3: how can individual, team and organisational competencies effectively be enhanced to support critical use of research evidence for the commissioning of services that better meet the needs of our multiethnic population?

• What factors in the wider societal and broader NHS context shape the routine, critical use of research evidence in commissioning for multiethnic populations?

• How does research (and other) evidence relating to ethnic diversity and inequality currently find its way into the commissioning process – through which actors and which routes?

• Who are the key actors and what are the key organisational settings and processes that present barriers against enhanced mobilisation and utilisation of evidence?

The bulk of this chapter is devoted to describing these wider contextual issues. However, in practice, many of the key informants also offered important insights into micro-level factors operating at the level of individuals and teams. We have noted these where relevant, although most were explored in greater detail through the case study work, which is presented in Chapters 4 and 5.

As noted in Chapter 2, our data collection did not focus narrowly on patterns of ethnicity evidence use but also solicited a wider range of information on commissioning structures and processes, and evidence use more generally. Key informant interviews were therefore loosely structured to allow respondents the opportunity to shape their responses and highlight the issues that they felt to be important. In particular, we did not offer any precise definition of ‘evidence’ but encouraged respondents to think broadly about the varied types of evidence (or knowledge) that play a part in commissioning work, with formal research evidence being just one aspect of this bigger picture.

Exploring generic commissioning drivers, structures and processes was important as these were likely to fundamentally shape the demand for evidence of different types as well as the access to, and use of, evidence within commissioning work. Further, an understanding of the more generic landscape was felt to be important in ensuring that any claims made for factors operating in relation to our focus on ethnic diversity and inequality were informed by an understanding of processes that shape and constrain evidence use in commissioning work more generally.

For this reason the findings in the present chapter are organised into three main sections: general findings relating to (1) evidence-informed commissioning and (2) ethnic diversity and inequality within English health-care policy and practice, followed by findings relating more specifically to (3) use of evidence on ethnic diversity and inequality in commissioning. Although research evidence did feature in respondents’ narratives, they also discussed a wide range of other types of evidence, reflecting the fact that these may often feature more prominently within commissioning work.

Respondents have been identified by their current broad role and sector but most had varied backgrounds giving them experience of different aspects of commissioning and evidence mobilisation processes. People in director-level roles have been identified as ‘senior managers’. More specific titles have been avoided to preserve anonymity.

What is health-care commissioning? What kinds of models are used?

The key informants varied in how closely they had been involved in commissioning work, yet all had sufficient exposure to commissioning organisations to provide useful commentary on the general features of commissioning structures and processes.

All respondents recognised commissioning as a complex set of activities, the intention of which is to shape health services to better meet population health needs:

I think, my sense is that commissioning actually covers a lot of different sorts of activities, but broadly speaking it’s the process of understanding the health needs of a population, and planning and procuring services to meet those needs. But within that, you know, there’s a lot of different sorts of functions, and different kind of patterns about how that might be carried out.

Third-sector manager and analyst

However, the consensus was that there was wide variation in the ways in which PCTs have been organised and commissioning work has been achieved in practice. Some respondents drew distinctions between PCT and local authority commissioning, but most felt that there was also important variability in approach and quality within each of these commissioning arenas.

To an extent, such variability might be considered to reflect an appropriately responsive system, in that no single model of commissioning might be suitable for all circumstances. Nevertheless, there was also a sense in the respondents’ reports that there remains a lack of clarity in terms of what ‘good commissioning’ might look like and significant contestation of roles and responsibilities within the commissioning arena. Moreover, although all respondents felt that commissioning should be an important lever for health-care redesign and improvement, most also expressed the feeling that the transformational potential of commissioning remains largely unrealised. For this reason it is important to examine the scope of variation described, with three distinct inter-related areas of variation evident.

First, respondents felt that there was important variation in the extent to which people in commissioning roles saw their job as one of transforming services to better meet needs as opposed to ensuring robust control of contracts and budgets (the so-called ‘transactional’ elements). Our respondents indicated that they felt that the former aspects were very important but were, in practice, not always emphasised:

I guess a broader role of bringing in, you know, not just the evidence, but . . . more widely [thinking] about the problems and how they would be resolved and what other bits of the system would be part of that. I think that’s what many of us would think was meant by ‘commissioning’. But then, you know, meeting people who have that ‘commissioner’ in their title, they, you know, often had a more contractual focus with the organisations, in terms of, you know, what would be delivered, and how it would be performance monitored.

Public health observatory senior manager and analyst

Second, respondents suggested that there was substantial variation in people’s understandings regarding the extent to which commissioning should be carried out exclusively by people formally identified as ‘commissioners’ rather than a diverse range of stakeholders being actively engaged (in assessing need, reviewing provision, identifying viable solutions and monitoring this process of ongoing improvement). Whether and how such diverse stakeholder working might be organised and managed in commissioning practices appears to vary widely:

It’s kind of, yeah, I suppose sort of two different views on what it is. Is the commissioning what commissioners do, in terms of tighter contractual type . . . of development, or is it, is it a broad role of a lot of people in the system?

Public health observatory senior manager and analyst

Third, respondents highlighted variation in opinions and practice regarding the extent to which commissioners and commissioning can, and should, contribute to the identification and implementation of service solutions, rather than focusing solely on the clear specification of outcomes required (so-called ‘black box’ commissioning). In other words, there appeared to be a lack of clarity in terms of where the boundaries of responsibility for different elements of service improvement might lie:

From talking to the voluntary sector in particular, they say their commissioners are not really particularly interested in that [service specification], it’s very much more about, well, how many people have you seen, is that in line with what we’ve asked you to see, and things. But actually understanding a bit more about what intervention is used and why it’s effective or not effective.

Third-sector senior manager

Commissioning is a fantastically blunt tool . . . quite a lot of commissioning is about bean counting . . . counting patients in, patients out.

Public health observatory senior manager

Notwithstanding this apparent variation in orientations to commissioning, respondents identified a range of more systemic factors that they felt made transformational commissioning difficult. Many respondents drew attention to the centrality of the relationships between PCTs and NHS provider trusts. They highlighted the greater political power of the provider organisations and the limited room for manoeuvre that this afforded commissioners whose budgets were felt to be (predominantly) tied up in large historical contracts and who often have no alternative source of provision:

I think the second big issue, which is a pertinent one, is really the momentum of the historical contracts . . . you know, a lot of what the commissioners are doing is almost working at the margins. Where you’ve got extra resources you can have a discussion about how they’re best deployed. Obviously most of the resources are in a basic set of core contracts to provide a hospital with an accident and emergency department, medicine and surgery and that kind of thing.

Public health observatory senior manager and analyst

I don’t think it works in a consistent, sustainable way anyway, because we’ve been pretty much, I think, commissioning the same [services] and we’ve very rarely decommissioned anything. So as commissioners – mental health services is a classic – it feels like we need to tear up the whole thing and start again. So . . . I think the whole thing isn’t working. The way that we describe it theoretically in the NHS . . . In theory that’s the way to do it, but in reality I don’t think it works anyway.

Strategic health authority senior manager

Some respondents drew attention to the inherent tensions and complexities in the system and particularly the lack of clarity around how a market-inspired model of commissioning should function in practice:

But [commissioning’s] origins have come out, you know, have come out of the purchaser–provider split, and I’m not sure how well thought through, in a sense there’s quite a lot of theoretical work about how providers ought to behave in a [market] You know, the model is an essentially market model, which is that you split the purchaser and the provider apart, and we kind of, there’s a model for how providers ought to behave, you know, faced with these incentives, but there seems to be much less work on what the incentive, you know, what should be driving commissioners or purchasers to do a good job.

Third-sector manager and analyst

What drives commissioning?

Across the board respondents felt that the major driver for commissioning action was currently a financial one. Some respondents noted that, although it was often considered to be taboo to explicitly discuss health-care rationing (with concepts of efficiency and value for money being seen as more palatable), a drive to cut costs did in fact underpin most work. Respondents noted that the prompt for PCT transformational work often resulted from national comparative data that indicated spend was high in a particular area, or national directives concerning ways of improving value and cutting costs:

You know, so in that sense the, often the driver of the commissioning is financial rather than more to do with the clinical and quality type issues. So that these things become a sort of add on to the contract, but you know, maybe almost irrelevant if somebody’s saying well you know, you need 5% efficiency savings this year.

Public health observatory senior manager and analyst

Several respondents also referred to the quality agenda and NHS Outcomes Frameworks93 as being influential in directing commissioning energy and resources.

That said, the key informants also felt that those national agendas that focused on other issues could be very influential in directing the work of PCTs. This is because PCTs were felt to be ‘obedient’ in this regard, such that national priorities would even take precedence over local needs and divert commissioning resource away from other work:

I mean if there is a national agenda on a certain something, vascular health checks programme is a clear example. No one had heard of that until three years ago . . . suddenly that became a key priority nationally and the PCTs were tasked to deliver that, and they then develop different models of delivering that within the PCT, and it’s suddenly happening.

GP/academic

Respondents acknowledged that the health inequalities agenda was prominent in health policy rhetoric, but felt that in practice this was not a major driver and remained a marginal concern within the commissioning work of most PCTs, where it was often equated with the work of the public health team within the PCT. One respondent used a football analogy, referring to public health commissioning as ‘minor league’ compared with the bulk of the PCT’s ‘premiership commissioning’ for primary and secondary care. Respondents noted the predominant focus of PCT activity on patients and service users – whether through a concern to curb demand or raise quality standards – and felt that this meant that the wider population, and inequalities in service access, are rarely a focus of attention for health-care commissioners.

Evidence use in commissioning

Most of the key informants expressed the opinion that evidence should be central to the commissioning process and that a wide range of evidence sources must be drawn on and synthesised to inform strong commissioning work, with formal research evidence being just part of this picture.

However, there was general agreement that, in practice, systematic and effective use of evidence was not routine. Respondents were aware of good examples in which commissioners had adopted a systematic and rigorous approach to mobilising and synthesising diverse sources of evidence to inform decisions, but noted that this was usually in response to a clear policy or local driver (e.g. an individual funding request) and that external assistance is often sought in undertaking this kind of more detailed work:

PCTs have got a record of delving into the evidence when they need to, certainly for making decisions about, you know, whether drugs are cost-effective or not, you know, there can be quite systematic reviews [of the evidence] that PCTs do.

Third-sector manager and analyst

Respondents felt that the variability in evidence use was in part explained by limited commissioning resource. They felt that commissioning work was often rushed and linked to annual cycles and budgets, and there was simply a lack of capacity to look carefully at each issue or draw on diverse evidence sources. This was felt to be contributing to a tendency to maintain existing patterns of purchasing rather than seeking to redesign services.

However, in addition to resource constraints, respondents highlighted the ways in which commissioners’ approaches to finding and using evidence are shaped by other factors. Respondents tended to agree that certain types of information and evidence are more prominent and more routinely used within commissioning than others, in particular those types of evidence that relate to costs, which appeared to reflect the prominence of financial drivers:

PCTs have large information departments and they link to their local public health observatories and they make use of data sets like the compendium . . . All the programme budgeting stuff, that looks at outcomes in relation to spend.

Third-sector manager and analyst

Some respondents expressed concern that there was sometimes very selective use of evidence on the part of commissioners, with evidence being used to provide support for decisions that have already been taken, rather than being used to inform understanding of an issue and thereafter guide an appropriate response. They also highlighted the political nature of commissioning and the way in which decisions can often be influenced by vocal interest groups – as one respondent put it, ‘whoever shouts loudest’ – rather than by a balanced review of the available evidence:

Evidence is not, you know, politically neutral, it either emphasises something, or you know, sort of backs up, you know, something that somebody believes anyway, or contradicts it, and therefore it’s, you know, it’s evaluated in that particular way. And one of the issues I think when you’re looking at things critically is that . . . sometimes you’re just looking for evidence to back up your point of view, as opposed to looking at everything out there, and I think that’s a big sort of issue as well around sort of commissioning.

Third-sector senior manager

In relation to research evidence, respondents generally felt that commissioners were most heavily reliant on national guidance and other forms of synthesised evidence, and that many commissioners did not access primary research evidence. Indeed, respondents referred to the process by which research evidence informed commissioning as both ‘ad hoc’ and ‘precarious’:

[It depends upon] people with a bee in their bonnet . . . in terms of the evidence bubbling up through other routes, that’s kind of a bit of a precarious thing.

Public health observatory senior manager and analyst

In some cases, respondents felt that this reflected the fact that commissioners were working on areas about which they knew very little. Research evidence was more likely to be drawn on either when particular researchers had built up a strong relationship with commissioners and were conducting research locally or when clinicians were engaged in the commissioning process, as these clinicians were considered more likely to be well versed in the evidence base relating to their area of expertise.

Further, several respondents felt that there was a need for commissioners, and the commissioning process, to expand and extend what counts as evidence and to recognise the value of different types of information and insight. In particular, these respondents were concerned that insight from patient experience and public consultation might potentially be very useful in improving services yet was not commonly drawn on in a systematic fashion to influence the commissioning process:

I mean there was a process about what is counted as evidence, and then what is published, you know, sort of a key thing. What is valued as evidence as well, and of course the value of evidence that is not random controlled trials.

Third-sector senior manager

Some respondents pointed to the lack of standards around good evidence use in commissioning. Several also felt that there was substantial variation in the skills and interests of different commissioning actors – variation that affected how evidence was brought into the commissioning process. Appraisal and synthesis skills were highlighted as particularly important for commissioners given the wide range of relevant information and the challenge of translating national guidance into local-level action. Yet these skills (appraisal and synthesis) were felt to be lacking and were often not recognised as a core requirement for commissioners. Some respondents also noted that, when commissioning teams are constituted to ensure representation of organisations or professional groups rather than skill sets, expertise in evidence-related skills can end up lacking. On this, respondent narratives suggested that commissioning organisations and teams rarely have assigned ongoing roles and responsibilities to identify or generate relevant evidence and channel it into the appropriate part of the commissioning process. Instead, evidence generation and evidence mobilisation appear to occur more as discrete, allocated pieces of work. For instance, a focused needs assessment may be commissioned from an external research company or a literature review may be undertaken by a specialty registrar in public health based at a PCT for part of their training:

They usually ask us [third sector/GP researcher] for the evidence . . . That’s an area that definitely commissioners do not have much expertise in, that I’m aware of anyway. There may be some PCTs who have evidence synthesis officers or something, but that’s something that we have spoken to our commissioners about [needing in future structures].

GP/academic

What we find is that commissioners are not very good at using evidence and understanding the different kinds of evidence that there are.

Third-sector senior manager

Some respondents also expressed concern that PCTs tended to use consultants for various elements of the evidence-gathering and synthesising tasks rather than developing these skills and subsequent in-depth understanding in-house. Consultants appear to be used regularly for a range of evidence-related tasks, including needs assessments, community consultation and insight work, research evidence syntheses, projection work and economic modelling:

I’ve always been sceptical where people sort of contract out a needs assessment, because it seems to me that has to be done by the commissioner, because they have to internalise that knowledge in order to be able to, over the next few years, commission those services better. They need to know everybody that’s involved on the provider side. They need to know the sort of broader population understanding.

Public health observatory senior manager and analyst

Respondents also highlighted the fragmented nature of commissioning work, so that evidence skills, even if available within organisations, often sit within silos and are not necessarily brought to bear where needed:

The bits of the process don’t always link together . . . the people who are perhaps particularly interested in evidence about best treatments, and you know, data about numbers and projections and things, are often within public health, are often not integral to the people who call themselves commissioners . . . so there may be good knowledge about evidence, but it’s not playing in at the right place at the right time to change contracts.

Public health observatory senior manager and analyst

Innovation through commissioning

Commissioning was not generally considered to be an important source of innovation by our respondents. Commissioners were often characterised as risk averse:

So if I give you the commissioners’ perspective, you know, at the end of the day we’re accountable for public money. I have to visibly show how I’ve spent it. New things are very uncomfortable.

GP

Commissioners were also felt to be distant from the realities of service delivery, making them unlikely to identify opportunities for innovation:

Examples of innovation are there, but these are despite rather than because of the system.

Third-sector senior manager

These observations linked closely to respondents’ opinions that ‘strong commissioning’ – commissioning that actually transforms services to better meet needs – has to involve a wide range of stakeholders. Several respondents highlighted the importance of having clinicians and other front-line practitioners closely engaged with the commissioning process. These respondents felt that this was essential to ensure adequate understanding of the realities of delivering the service and that health-care practitioners with this understanding were therefore more often a source of innovation. They also noted that, even when the impetus for change comes from commissioners, providers have to be committed to the innovation for it to happen:

There was an end of life care [project] . . . it worked with the palliative care commissioners and also with heart failure nurses, so it was a carers’ organisation . . . but they worked really well with commissioners, and also they had really self-critical evaluation about what difference they made . . . and it influenced the strategic plan around palliative care, because the commissioner was involved from the beginning, in fact they were joint bidders.

Third-sector senior manager

Some respondents also felt that innovation is more likely when the commissioning process draws in the public and potential users of the service in a meaningful way:

So the local authority absolutely threw a fit right at the beginning, saying, you know, ‘what do you mean you’re going to put a mental health unit in the xxx?’ And then slowly as we’ve got them on board, then we’ve got the local authority on board . . . And it only got off the ground, and that design only worked because it was the public who asked for it.

GP/ex-senior commissioner

A couple of respondents identified a further characteristic of commissioning work that they felt often undermined the potential for innovation, namely the failure to carefully evaluate service redesigns. These respondents felt that commissioners tended to focus on ‘bottom-line’ outcomes rather than generating learning through unpacking the processes and understanding what did and did not work as anticipated.

Nevertheless, some respondents did feel that PCT commissioning was improving, and that progress was being made, at least in some areas, towards more responsive and impactful commissioning that took population health needs as the focal point:

In terms of structural thinking I think PCTs were a really good invention; they were bringing public health down to a local level, using that to inform commissioning process, really having responsibility for linking in with primary care providers. I think there was a lot of potential there . . . innovative thinking . . . I do see that that would have come in time.

Third-sector senior manager

Marginalisation

An important theme within the key informant interviews was that attention to ethnic diversity and inequality remains a marginal concern within English national health-care policy:

I always say that people don’t get discriminated any more, the equality and inclusion agenda gets the discrimination . . . it’s the area itself that gets the discrimination, that gets less resources, that gets the less importance . . . Which of [the] agendas do you think is going to be keeping people awake at night time? It will not be the inclusion agenda. It will be QIPP and commissioning and providing. So there is a hierarchy in the importance of areas within the NHS.

Strategic health authority senior manager

There was some disagreement between respondents in terms of whether there had been any progress during the period of the Labour government (1997–2010), with some feeling that real progress had been made within the DH and central policy during this time and others suggesting that there had never been genuine commitment from the top to make this a core policy driver. Nonetheless, respondents agreed that other priorities and agendas tended to take precedence and they drew attention to the ways in which equalities work could be presented as conflicting with, rather than aligned to, other priorities:

They don’t have to be, but in this modern world where senior decision makers don’t understand the equality inclusion agenda, and often some of them don’t believe in that agenda, then it becomes conflicting, yes, it’s one or the other.

Strategic health authority senior manager

Several respondents drew attention to the apparent synergies between the quality agenda and equalities issues but noted that in practice there was very little connection at national or trust level. One respondent had spent time reviewing quality accounts across a large number of trusts and found that they had been prepared with little or no reference to equalities issues. Others explained the need to convince people working on quality issues of the relevance of taking an equalities focus:

If you look at quality one of the big features in and around that is around patient experience. How can you get patient experience right if you’re not disaggregating and getting the patient experience, whether qualitative or quantitative, of all the different groups that are using those services? I think for those people leading on quality, until you start talking about all of that, they don’t really get it at all, they just really see it as ‘oh E&D, that doesn’t really apply to us’. But actually you can’t really achieve quality for everybody unless you achieve equality in that process.

Strategic health authority senior manager

[QIPP] has a financial component in it, but to be interrogating that in terms of equality as opposed to just quality, no. It was not part of the package.

Third-sector senior manager

Several respondents also highlighted the way in which the national health inequalities agenda has lacked adequate reference to ethnicity, opting to understand inequalities primarily in terms of differences between geographical areas and socioeconomic groups:

Every review of health inequalities has excluded ethnicity. The previous one said they couldn’t do it because the data wasn’t good enough. Now the data’s good enough . . . [but] until there is some sort of ‘must do’, ‘have to do’, I think we are not going to [do it].

Public health observatory senior manager

I said repeatedly that it was completely unhelpful that the previous policy agenda had health inequalities here and the equality agenda here [indicates with hands wide apart]. So the equality agenda was formulated in terms of the law and fairness and justice and non-discrimination and so on, whereas the health inequalities agenda was coming from a different perspective.

Third-sector manager and analyst

The only exception to this picture of marginalisation was in relation to mental health work, in which several respondents highlighted significant national policy drivers to understand and tackle ethnic inequalities. However, even in relation to mental health, some respondents felt that progress had been disappointing and that gains on the ground had not been matched by system-wide changes to mainstream ethnic inequality within commissioning work.

Respondents felt that this general lack of strong direction from national policy-makers was often reflected at the local level in the behaviour of PCTs. They felt that in most PCTs there was no sign that attention to ethnic diversity and inequality was embedded within the main commissioning processes. Some respondents felt that attention to ethnic diversity and inequality had largely been confined to an internal human resources issue, or had taken on a very narrow legal compliance focus within PCTs, rather than being a fundamental part of knowing and responding to the health needs of the local population. One respondent even referred to a ‘get out of jail free card’ to signify the way in which PCTs showcased a one-off project focusing on ethnic inequality issues, in lieu of being able to demonstrate a consistent and embedded approach to this axis of inequality.

I think locally it still remains a very Cinderella issue I think for many groups, for many areas . . . I think overall it’s probably still not that high on people’s radar, is it?

Third-sector manager and analyst

I think because we’re still moving from what is a very white Anglo-centric approach to health care to recognising difference as part of our community, rather than something that if we’ve got time and leisure we’ll deal with.

Third-sector senior manager

PCTs seem to have interpreted a lot of this, a lot of them have tried to meet the legal duties, you know . . . you know, the action was taken to write equalities schemes, and comply with the law, and . . . there was almost a sort of disconnect, you know, inequalities, the racial and ethnic inequalities really related to writing a race equality scheme, at the time. But actually, if you really, you know, a PCT that was doing something about this would have its public health people kind of, you know, embedded and immersed in that whole agenda, and not its human resources, you know, legal people, who were writing this document.

Third-sector manager and analyst

Importantly, several respondents highlighted the fact that there had never been any performance management focused on ethnic (or other) equalities-related outcomes. Respondents noted that this meant that the work had not been a ‘must do’ and that, in the target-driven culture of the NHS, this absence of either a carrot or a stick had served to keep the issue at the margins:

There is a prior problem here, which goes back to the regulation side. If this isn’t monitored, as you know, a national priority, then most people are not going to worry about it are they?

Third-sector manager and analyst

We measure everything else within the NHS. We’ve got targets; over the top most of the time. But around this agenda, we’ve never really had measurement.

Strategic health authority senior manager

Some respondents noted significant variation in the extent to which ethnic inequality is taken seriously in commissioning organisations. However, respondents felt that this gulf had not changed much over time and that there could well be slippage backwards in the future, with organisations becoming less attentive to this issue:

I think you’ve got a big continuum haven’t you from the people who are engaged, switched on and fairly active in this area, right through to the other end, to people who say ‘what?’ And that’s always been there, because that’s one of the things I’m struck by, is over the last ten years, it’s always been . . . one or two proactive [places] like that, and there’s all these others where there is less happening. Why has that whole curve not shifted over time? It doesn’t seem to have.

Third-sector senior manager

Ignorance, ambivalence and obstruction at senior level

Some key informants suggested that the marginalisation of the ethnic equality agenda within the DH and the NHS could be explained in part by ambivalence and complacency on the part of senior leaders and in part by their need to prioritise action within a host of competing agendas. As one respondent put it, there are ‘many distractions’. Thus, some respondents drew attention to senior policy-makers who they felt were not convinced that important ethnic inequalities exist, or who they felt believed that such issues are already understood and dealt with without the need for specific measures:

So I think there’s something around people not seeing it, not seeing it as important.

GP

Decision makers who feel that we already have a fair society, that we already have an equal world, that we already have a very civilised society, so therefore all this inclusion and equality resources that we’re putting in is political correctness gone mad.

Strategic health authority senior manager

In London, in many places, my sense is that there is a belief that – of course we’re commissioning for BME needs . . . we have been doing that for years, so what’s your problem?!

Third-sector senior manager

Other respondents felt that the default position within the DH and much of the NHS is simply to overlook the relevance of this dimension:

Nobody in the Department of Health thinks about it. I think the information centre is all in different bits so they don’t necessarily join up on this. I wish I could think that there was a conspiracy theory – I just think it’s default.

Third-sector manager and analyst

I go to meetings so many times and I’m the only black face there. And I know this issue of equality is happening but nobody raises it. They just try to ignore it. And so you do raise it, people like me have to raise it, because if nobody else will, I always will. But it shouldn’t have to be that way.

Strategic health authority senior manager

However, some respondents also drew attention to more active forms of obstruction and undermining that they felt were linked to the protection of professional boundaries, vested interests and the contestation of minority ethnic entitlement and representation:

It [race equality] is divorced because people have got a monopoly on health inequalities. Those people who are working in it don’t want the inclusion and equality agenda to be anywhere near it because they’re protecting their own jobs, their own little power houses. That’s what it is, the reality of it from my experience, that’s what I think . . . Otherwise actually inclusion and health inequalities fit very nicely together. It’s a natural fit.

Strategic health authority senior manager

The other dimension where the local authority’s involved . . . is [where] you start to get into a political dimension about who ‘our people’ are, and you know, where we should be focusing resources on, on local people, you know and that, and that, there’s a risk that . . . local people can actually be, you know, stereotyping that as, someone who was born and bred in the area . . . and all these other groups are kind of not necessarily local.

Public health observatory senior manager

Most respondents also identified a lack of comfort in raising issues related to race and ethnicity that served to silence discussion and further marginalise the agenda. Respondents noted that people could often be fearful and perceive the topic as politically sensitive and complex, with the result that they would try to avoid it:

I think it’s uncomfortable, because, and part of it’s around what we view as politically correct and not politically correct . . . otherwise we’d be talking about it quite openly. There is an element of, it’s a bit of a taboo subject.

GP/ex-senior commissioner

There was certainly a degree of concern about either stereotyping or, you know, sort of representing communities in particular difficult ways . . . and so it’s one thing to be aware of the background, it’s another thing to say certain things up front and out loud.

Local authority consultant

They had a race equality review as part of being a Race for Health PCT, but nobody would talk about race equality in the room, we were with their board, all the senior people . . . The local authority and the PCT are absolutely – it’s the same in XX – absolutely terrified that there’ll be a backlash if they focus on BME communities.

Strategic health authority senior manager

Notwithstanding possible variation in the underlying attitudes and perspectives that might characterise particular actors’ avoidance of or obstruction towards the ethnic equality agenda, key informants felt that a lack of senior leadership and an absence of concern regarding ethnic inequalities were common across PCTs: ‘Very rarely do we get key players at a senior level pushing this agenda’ (strategic health authority senior manager).

Lack of infrastructure and resources

Respondents felt that the ethnic equality agenda lacked adequate infrastructure and resources at national and local levels. They pointed out that central initiatives that could be helpful, for instance the NHS Equality and Diversity Council, were not effectively connected to what happens on the ground within PCTs.

At the level of local PCTs, respondents noted the varied location and number of staff within each organisation who had an E&D role and responsibility. This was felt to usually be a small resource that was isolated from core commissioning work. Some commented that it was rare to have senior posts devoted to this agenda and contrasted the limited investment in this area of work with the investment in agendas with greater legitimacy. Moreover, respondents felt that there was often a heavy dependence on just one or two people within organisations, often individuals of minority ethnic identity themselves, who were tasked with pursuing this agenda and acting as spokespersons for very diverse communities. Respondents referred to such staff ‘battling’ alone and becoming frustrated and exhausted:

One person appointed on equality to make that happen is very demanding. It’s draining. It won’t happen . . . We would never expect QIPP to be done on a part-time or voluntary basis.

Strategic health authority senior manager

Elsewhere, some respondents noted the reliance on unpaid community representatives to provide relevant input to commissioning processes. Meanwhile, respondents also felt that PCT structures and processes rarely linked E&D activities effectively into other elements of the organisation and did not hold staff members elsewhere to account on this agenda. For example, equality strategies and equality impact assessments, although useful in theory, were identified as often being tick-box exercises that were not linked to action:

How are the priorities, as set out in the Single Equality Scheme, linked back to the strategic plans of that organisation? Most of the time they sit out in a vacuum and most of the time the priorities set out in the Single Equality Scheme don’t even feature anywhere near any of the strategic business plans at all.

Strategic health authority senior manager

Lack of confidence and competence among commissioners

A further important theme highlighted by key informants related to the lack of confidence and competence to address ethnic diversity and inequality among commissioning staff. Respondents felt that in some PCTs the lack of diversity within the workforce and the lack of connection to issues of inequality contributed to low levels of both confidence and understanding. They were also concerned that PCTs had been quick to cut engagement and equality posts in ongoing restructuring, thereby removing people who might have otherwise contributed a sustained understanding of minority ethnic needs and experiences.

As before, respondents noted that external consultants were often being called in from outside, so that expertise and resources tend not to be mainstreamed or embedded. And again, there was felt to be a tendency for PCTs to assume that members of staff from ethnic minority backgrounds would provide the necessary source of insight and would champion this agenda. Yet this went hand in hand with substantial reluctance on the part of some BME professionals to take on the mantle of this role (in part as a result of the marginalisation and exhaustion experienced by others, as described earlier). Elsewhere, some key informants reported a general unwillingness, both in themselves or amongst colleagues, to consistently raise the issue of ethnic inequality when other people did not, primarily because they were concerned that they might be perceived to be conflating personal and professional issues. Respondents also noted that, although public health might be considered the natural home for inequalities work within PCTs, this did not necessarily translate into a consistent and careful consideration of ethnic inequality amongst public health staff, this instead being highly dependent on individual confidence, expertise and interests.

Respondents also felt that commissioners could often hold unsophisticated understandings around ethnicity and often had a tendency to stereotype rather than recognise intragroup heterogeneity and changes in group needs, aspirations and experiences over time. These respondents worried that commissioners essentially tended to blame minority ethnic people themselves for poor access or poor experiences rather than considering potential limitations of the services on offer. As such, these commissioners were felt to equate responding to minority ethnic needs with the need for additional resources and/or special services:

So some people [commissioners] are a bit wary of going to certain groupings . . . [I’m thinking of] a very well educated executive who wouldn’t be willing to go to any of these, any of these meetings [with the Somali community] . . . I suppose internally within the system we’ve stereotyped what groups ask for, so what’s happened is actually without going out they’ve just assumed it’s going to be an angry mob.

GP/ex-senior commissioner

At the same time, however, respondents acknowledged the ways in which understanding and responding to ethnic inequalities can be complex and challenging. In this, they pointed to the need for greater support and direction at national level to equip commissioners to respond appropriately to these complexities and challenges.

Nonetheless, respondents’ narratives suggest that the lack of a wider supportive context means that there is no particular impetus for commissioning managers or their teams to recognise or address their low levels of understanding, confidence and competence, and no clear penalties for failing to do so: ‘People don’t know what they don’t know and so avoid it altogether’ (DH senior consultant).

Competing ways of making the case

Reading across and between the key informant interviews revealed the varied and conflicting ways in which the need for attention to ethnic diversity and inequality within health-care policy and practice is framed by different actors.

Interestingly, most respondents felt that focusing on legal duties had not been productive, serving instead simply to reinforce a compliance or ‘tick-box’ mentality rather than encouraging people to take ownership and enthusiastic action. Moreover, although some argued that social justice and discrimination provides the only legitimate frame of reference, others found this focus to be unhelpful and off-putting, and some even felt that framing the issue always in terms of inequality was potentially stigmatising and disempowering for minority groups: ‘The moment you raise the race agenda, people back off because they’re scared’ (third-sector manager and analyst).

Some respondents were particularly concerned about focusing on racial discrimination within the health service, which they felt had been overplayed and had served to alienate key actors who needed to be persuaded to work towards the same objectives rather than defending their (in)action. Others also argued that a predominant focus on racism, particularly within the mental health service arena, had diverted attention away from understanding a wider range of factors that might also contribute to higher levels of ill health amongst minority ethnic populations, including wider social disadvantage.

Elsewhere, some of the key informants talked about people strategically aligning the agenda with the ‘flavour of the month’, and worried that this made equalities work vulnerable to short-termism and threatened longer-term gains:

Equality and fairness on its own is an important area, and those leaders who lose that, lose a very fundamental thing. You can’t pick and choose equality and fairness into different areas. Human rights and fairness is a given for everybody. It’s the cornerstone for any business . . . It should be because it’s the right and the fundamental thing to do . . . It doesn’t have to be linked with QIPP. It needs to stand on its own as a priority. Let QIPP come to human rights and equality and inclusion area.

Strategic health authority senior manager

However, others argued the case that equality was genuinely an integral part of quality and efficiency issues and wanted to see a greater effort to position it more closely with these agendas regardless of their recent emergence as topical drivers of commissioning practice. This was felt to be part and parcel of mainstreaming inequalities work within, and aligning it to, core processes: ‘[We need to have] equalities embedded in the boring stuff that people feel they had to do, because that’s the way that people accept it as part of the institutional framework’ (NHS manager).

However, some examples of respondents’ aspirations for such alignment used language that did not necessarily serve to focus attention on ethnic health inequalities:

We aligned it [diversity and equality] with world-class commissioning . . . if you look at the competencies they apply to any commissioner really . . . So competency 5 was about knowing your population and the health needs of your population. Competency 3 was about partnership and how you’re engaging at a local level and all those.

Strategic health authority senior manager

Perhaps unsurprisingly, some respondents also pointed to the need to ensure that arguments for paying greater attention to minority ethnic needs were framed in terms of cost savings and/or efficiency:

What happens is things are pulled, because financially our situation has changed, and so therefore the priority is to take things off the table, and it becomes a bit of a soft target.

GP/ex-senior commissioner

If the condition is leading to increased cost, admission rates, referral rates, then we won’t have to give them any evidence, they’ve got that evidence and those are key priority areas for them, to reduce admission rates, reduce referral rates.

GP/academic

Several of our key informants were themselves aware of the potential conflicts between, for instance, arguments based on potential cost savings and those focused on issues of social justice, and felt that progress could be (and had been) undermined by advocates pulling in different directions. Some argued instead for the need to use a variety of arguments – as one respondent said, ‘to pump on all sides’ (third-sector senior manager) – to increase action on this agenda.

Enhancing health care for minority ethnic people: a role for commissioning?

Most of the key informants we spoke to considered commissioning to have a key role to play in improving health care for minority ethnic people and tackling ethnic inequalities:

Our philosophy and approach round the whole equalities agenda, because it really does need to sit in the heart of commissioning, and that’s half your battle over once you get the commissioning end of it right.

Strategic health authority senior manager

Although recognising that there are issues with providers around race equality, the real lever for change lies within commissioning.

Third-sector senior manager

Two aspects of understanding and addressing ethnic diversity and inequality highlighted by respondents seem particularly tied to the commissioning role. First is the importance of understanding the health needs of the whole population, including the needs of those people who are not already accessing services. Second is the need to address shortfalls in the ability of current provider organisations to deliver the types of services that are required to meet diverse needs, that is, the need to ‘develop the market’.

Although respondents saw commissioning as a real lever for improvement, they also recognised that significant progress still needs to be made, and that commissioners have hitherto rarely pushed the agenda. Some key informants felt that provider organisations, particularly committed health-care practitioners or third-sector organisations, were most often the current source of innovation around meeting minority needs: ‘This comes back to a committed clinician identifying a need and doing something about it’ (third-sector senior manager).

Although respondents identified some PCTs that had achieved a more embedded approach to considering and addressing ethnic diversity and inequality, they generally felt that their responses had been piecemeal – being characterised by passionate individuals and short-lived projects, or being prompted by some kind of serious problem rather than being proactive and sustained:

The whole of this needs to feature right the way through that [commissioning cycle], so right from identifying needs. So you identify a particular need, you then find the right providers to commission that and then build into the requirements what it is that you want them to specifically do. Whereas, at the moment, we don’t . . . We kind of commission whatever service and just commission it for the whole population but not really set any requirements for different parts of our population that might need to access that service or experience that service in a particular way.

Strategic health authority senior manager

Patterns of evidence use

Most respondents argued that evidence use should be a big part of effective commissioning for multiethnic populations and that a wide range of complementary evidence sources were useful at different stages of the commissioning cycle:

There’s information at all sorts of levels. There is the demographic stuff, just knowing who’s living in your patch . . . the epidemiological information . . . the health observatory work and other sources, what that means in potential need for services . . . But then there also needs to be the opportunity to engage with representatives of local communities . . . where commissioners actually listen to what is being said about what is needed.

Third-sector senior manager

However, perhaps reflecting the wider marginalisation of the ethnic equality agenda, and the patchy use of evidence more generally described above, all respondents felt that in practice there was often very limited use of evidence on ethnic diversity and inequality within commissioning work.

In terms of understanding population health needs and identifying gaps in provision, most respondents emphasised the central importance of good ethnic monitoring data, particularly in primary care, as this was felt to offer a population-level ethnic profile.

Some respondents also drew attention to the potential of JSNAs to widen the focus of commissioning beyond those who already engage with services to those with unmet need. Nonetheless, these respondents raised concerns about the current lack of adequate depth of JSNAs in relation to minority ethnic communities and their weak connection to either strategy or action: ‘What we found from that evaluation [looking across a region] was that JSNAs themselves don’t disaggregate [population groups]’ (strategic health authority senior manager).

As before, respondents were often aware of examples of good practice, for instance when special pieces of needs assessment work had been commissioned by PCTs, but felt that these were usually the exception rather than the rule:

What they did was set up their own engine around patient profiling and they supported their GP practices. I think they’ve got well over 50% now of GP practices or more who are doing the patient profiling, and they’re not just doing it by ethnicity.

Third-sector manager and analyst

In relation to identifying solutions and procuring services, key informants thought that it was rare for service specifications to include detail on how services should address ethnic diversity or tackle inequalities. One respondent felt that, even when commissioners were aware of the need for service providers to address ethnic inequalities, it would be unusual for commissioners to compile evidence around potential service responses or to use such information to inform the service specification, with one respondent noting that this would be considered ‘a nicety not a necessity’ (GP respondent with extensive past commissioning experience).

Respondents felt that practitioner experience and insight could be important both in flagging up problems and in identifying viable routes of intervention to improve services for minority ethnic people. Key informants gave examples of clinicians raising issues and pushing for appropriate responses, and also of some PCTs that had facilitated inputs into the commissioning process from community development workers, thereby gleaning important insights about unmet need and poor service experiences. But once again, respondents often felt that these aspects generally needed further strengthening.

Finally, in terms of monitoring performance and prompting further improvement through the analysis of service processes and outcomes, respondents gave few examples of contracts, key performance indicators (KPIs) or performance review mechanisms being used to generate information on service performance in relation to different ethnic groups. Several participants regarded evidence of patient experience, whether generated through qualitative or quantitative data sources, as an important potential source of information. Nonetheless, they felt that this evidence was often not drawn on by commissioners, and was rarely disaggregated by ethnic group. Indeed, even when respondents described initiatives to commission new services that met the needs of an ethnically diverse patient population, it was rare for these to also include provision for monitoring against ethnicity-specific outcomes:

So, the thing about ethnic minorities, making sure there’s stuff in there [in contracts] about equality, doing equity audits, using interpreters and so on. But then I think it’s worth doing, because you know, most professionals will take on-board those things, but on the other hand there’s almost never the capacity to actually monitor whether that’s really happened in practice . . . so monitoring is very unsophisticated.

Public health observatory senior manager

Gaps in data and evidence

The key informants identified a range of issues relating to the quality and quantity of available evidence on ethnic diversity and inequality that contributed to the low levels of usage described above.

First, most respondents highlighted the absence of a detailed consideration of minority ethnic needs within many influential policy documents, such as National Service Frameworks (see www.nhs.uk/nhsengland/nsf/Pages/Nationalserviceframeworks.aspx). Second, many respondents highlighted the persistent poor quality of ethnic monitoring/patient profiling data within service settings, and particularly within primary care. Third, many respondents felt that there was still little evidence on how services should be shaped to address ethnic diversity and inequalities. One respondent described this situation as ‘scandalous’, arguing that the academic public health community had failed to provide an adequate steer for commissioners on ‘what works’ to reduce minority ethnic disadvantage (as well as other health inequalities). Several respondents noted that, in the absence of alternatives, commissioners predominantly drew on national syntheses of evidence, such as those produced by NICE, and that these include very little detail on how to shape services for minority ethnic populations. Fourth, respondents pointed to the lack of all-important information on the cost-effectiveness of interventions/service modifications, something they argued was essential in the current climate of cost-cutting to build appropriate business cases for selective dis- and reinvestment.

Notwithstanding the gaps in the evidence base, key informants also felt that commissioners could often be guilty of overlooking potentially important sources of evidence or assuming that there was a lack of evidence when this was patently not the case. For instance, some respondents pointed out that ethnic monitoring data is often more complete than might be imagined and that there are strategies that can be used to work around incomplete data and produce useful information. Yet they felt that commissioners frequently did not request such data from provider organisations. Indeed, the general failure on the part of commissioners to ask such questions of the data that were available was highlighted by several respondents:

What we found was the commissioners were really, really weak on setting these requirements in terms of this cycle for the providers. When we went to talk to the providers, the providers were saying actually we’ve got loads of data and evidence that we collect but the commissioners never asked for it around ethnicity.

Strategic health authority senior manager

Some respondents also noted the many missed opportunities for generating evidence through the careful piloting of innovative interventions. They felt that too many initiatives aimed at addressing minority ethnic disadvantage were short-lived and remained unevaluated, so that lessons were neither learnt within the organisation nor shared more widely. Some respondents also felt that commissioners were too reluctant to seek out and learn from interventions developed and tested elsewhere; in the words of one respondent, there is a culture of ‘if it’s not made here then it doesn’t fit’ (third-sector senior manager). Similarly, they felt that too few commissioners drew on national data and research evidence to inform their local picture:

I think most of the time people don’t know how to use the national published research at all, and I think if you look at commissioning . . . I think there’s a lot of work to be done with the commissioning teams . . . I think there’s a major issue about their capability and competence to be able to use [evidence].

Strategic health authority senior manager

Many of the key informants felt that commissioners were not generally good at drawing on the expertise of, and insight from, third-sector organisations or service users and members of the public from minority ethnic communities, to fill gaps in their understanding of need or identify viable solutions:

There are many sources and we need to look beyond the kind of NHS sources as well, because there are lots of third sector organisations, both regionally and nationally or locally that might be working with some of the groups that have far better information about their communities on certain health issues, but we’re not really gathering that. Even when they’re coming to us as the advocates or the activists through their local interest networks or whatever and giving us that information, is it making the journey into commissioning for example? I think there are serious question marks about that.

Strategic health authority senior manager

Well in central XX we have no XX service, and there’s no patient there coming forward, because they’re not as coordinated, they can’t speak the language, they can’t articulate very well what their needs are, and so therefore they can’t really, they have very little advocacy, and so you have that disparity which plays out in the system too . . . you’ve already silenced the voices if that makes sense, of a lot of ethnic minority groups, because they don’t understand the system, and they have very few people who represent them in the system.

GP/ex-senior commissioner

In addition to missed opportunities to draw in relevant evidence, some key informants bemoaned the lack of a push from commissioners to improve processes of data collection, analysis and reporting. In particular, respondents noted the persistent lack of commissioner pressure for better ethnic monitoring: ‘I think the London Strategic Health Authority actually set targets for their PCTs and GPs to roll out ethnicity recording. But . . . it’s always been patchy’ (third-sector manager and analyst).

Some felt that continued scepticism about the value of ethnic monitoring among some practitioners and commissioners tended to hamper progress. In contrast, others felt that it reflected a basic lack of will power to prioritise this area, or even suggested an intentional resistance to collecting and reporting these data:

The lack of data is actually kind of a useful shield for people to do nothing with as well, so you know, the fact that we haven’t put ethnicity high up in any of this is because there hasn’t been data, it’s not in anyone’s interest to have data, because then, then you might see something you have to fix.

Third-sector manager and analyst

Conceptual and practical challenges

In addition to their more general observations on the quality and quantity of evidence relating to ethnic diversity and inequality, the key informant interviews highlighted a number of important challenges that are encountered in generating and mobilising evidence on ethnic diversity and inequality.

First, respondents noted a range of challenges relating to describing patterns of health and health care by ethnicity, including high levels of population turnover and the need for regular updating; a lack of enumeration of smaller ethnic groups rendering them invisible in quantitative data; and heterogeneity within ethnic categories and the need for more detailed breakdowns (such as by age, language competency, migration status or religion).

Second, some key informants identified a range of complexities relating to commissioners’ broader understanding of poor access, poor experiences and poor outcomes for minority ethnic people; and particularly the importance of unpacking the underlying causes to identify potential interventions that might be prescribed by commissioners. For instance, key informants highlighted the complex relationships between minority ethnic identity and low socioeconomic status, and between minority ethnic identity and migrant status:

All the things that come with low socioeconomic status, are a factor in it, but . . . there’s various aspects to culture and language and other things, you know, entangled with this . . . you know, you’ll need to think about the two things at the same time, but conceptually it’s quite tricky . . . but I think this is a real problem . . . because I think unless that gets, you know, straightened out it is very difficult for people to know what they think they’re doing, and understand ‘what is this problem we’re trying to solve here?’

Third-sector manager and analyst

Third, the interviews highlighted challenges in relation to identifying effective responses to unmet need and inequalities. Respondents noted a lack of guidance on how findings on the effectiveness of interventions should be translated across different contexts, and the need to weigh up the pros and cons of specialist service responses compared with the pros and cons of efforts to accommodate diverse needs within mainstream services. Some respondents also felt that it was difficult for commissioners to establish feasible approaches to monitoring service outcomes by ethnicity and thereby determine the degree of success of service modifications.

More generally, several respondents alerted us to the need for work that more clearly identified standards and expectations around commissioning services to meet diverse needs and address inequalities. They felt that pockets of innovation and progress often existed in isolation, and that more sharing of lessons learned was needed to establish common understandings and encourage more consistent attention to these: ‘You know, the idea of what good practice would look like, I think that is a question worth bottoming out’ (third-sector manager and analyst).

Mobilising evidence for improved services

There were somewhat mixed views among the key informants in relation to how important the generation and application of evidence might be to the goal of improving service access, experiences and outcomes for minority ethnic people.

Some respondents recognised the increasingly strong discourse around evidence-based policy-making and felt that a lack of data and evidence on ethnic diversity and inequality presented a major obstacle to action. As mentioned earlier, respondents were concerned about the absence of detail on minority ethnic health needs, particularly in JSNAs, which they felt undermined efforts to make progress in this area; as one respondent said, ‘you’ve lost at first base’ (strategic health authority senior manager). Likewise, respondents felt that the limited evidence on effective interventional strategies to address ethnic inequalities was a major impediment to action in the current climate:

I think part of it [lack of attention] is due to lack of information . . . a lot of the data on access to services and so on just isn’t there by ethnicity.

Third-sector manager and analyst

Because that’s the other thing that then inhibits people, is saying, ‘OK, so you’ve told me what the problem is, let’s do something about it’, ‘oh well let’s do an evidence based response to this’, and of course you’re back in the woods again, because you don’t know necessarily what’s going to work.

Third-sector manager and analyst

These respondents also emphasised the importance of rigorous evidence use, arguing that poor analysis leads to inappropriate responses. Some even accused other stakeholders of ‘muddled thinking’ and questioned the extent to which programmes of work aimed at tackling ethnic inequalities – such as Delivering Race Equality94 and Pacesetters95 – had been sufficiently ‘evidence based’:

You do the epidemiology and guide your prioritisation and your actions on that basis, rather than just treating people as a homogenous group of black or Asian people, do you know what I mean? I think sometimes the race agenda didn’t do itself any favours by taking that kind of victim role all the time . . . So I think if you really want to tackle the problem you need to do your diagnostic properly and scientifically. I think that’s really what I’m saying. We need to bring science to it.

Third-sector manager and analyst

In contrast, other respondents, although acknowledging the contribution of data and research evidence, questioned whether weaknesses in this area were really the most significant obstacles to progress towards improved services:

It just feels like some of it, it’s not rocket science to find out what’s happening with some of the black and Asian communities [in town X] . . . I could have told them that at the age of ten, some of it. But yet, nothing significantly – we’ve been doing things at the edges, tinkering at the edges . . . the Asian population is huge [in town X] . . . Yet in terms of commissioning and targeted interventions of that community, it’s still not . . . you know. It’s the same in Y; any community you look at.

Strategic health authority senior manager

Selective research, selective thinking. For example, if they want to progress on, say, diabetes within the Asian community, or infant mortality amongst Pakistani women, there’s enough information out there that tells us exactly where the issues are, where the concerns and the problems are. What stops people doing that? . . . There isn’t that passion to make things happen for that particular group.

Strategic health authority senior manager

Linked to this awareness of other, more systemic factors blocking action towards improved services, several respondents talked about the need to connect decision-makers to the issues and felt that evidence needed to play a role in this, acting in an influential rather than a purely instrumental way. A combination of personal stories alongside hard facts was thought to be particularly powerful here, with one respondent describing a ‘pincer movement’ to influence key decision-makers, bringing together national statistics showing the scale of an issue with an authentic personal narrative, so that the ‘light bulb goes on’ (third-sector senior manager).

Respondents also emphasised the need for ongoing engagement and persistence, as audiences are often not already primed and progress is likely to be slow:

Just evidence to show that, how badly people are dealing with a particular issue, that needs to be almost a starting point.

Public health observatory senior manager

I think part of the challenge really for a lot of, and especially with the new GP commissioners, is getting them to understand that there might be a problem here.

Third-sector manager and analyst

Respondents also talked about the importance of the credibility of the evidence and its bearer, and the significance of using peer networks – particularly among clinicians – to effectively mobilise evidence. They felt that different audiences were comfortable with, and valued, different types of evidence (particularly whether this was qualitative or quantitative evidence) but that many commissioners recognised the need for instrumental, ‘how to’ evidence most readily:

GP/academic: I think they need statistics, in terms of if there is a problem in access, in referrals, you know, in high referrals, low referrals, mortality, I think you need to have evidence, you need, only then will someone start looking at it, if you don’t have any evidence they will say, ‘Well what, there doesn’t seem to be a problem’.

Interviewer: And particularly the quantitative evidence?

GP/academic: Yes, so much so.

Commissioners want some information, but mostly solutions with a business case.

NHS manager

Perhaps of particular significance in this area, respondents expressed concern that evidence brought to commissioning relating to minority ethnic health needs and potential solutions is often subjected to higher quality standards than that required for other issues: ‘The proof that is required for commissioning mainstream services is of a far lower level than the proof that is required for commissioning specialist services’ (third-sector senior manager).

Although respondents recognised that the current financial climate meant that any proposal would be likely to be challenged, they felt that there were two key additional factors that meant there was usually closer scrutiny of ethnicity-related evidence. First, responses to ethnic inequalities are often constructed as new and additional to, rather than as improving the quality of, existing services. Second, commissioners are usually distant from these communities, lack understanding of their needs and are fearful of taking risks. One respondent noted that these factors together tended to raise significant obstacles to action on inequalities with ‘people waiting for the evidence base for years’ (GP).

Research question 2: how does organisational context shape the mobilisation and utilisation of knowledge relating to ethnic diversity and inequality?

• How often, and at what stages, do managers apply research evidence relating to ethnic diversity and inequality in their commissioning tasks?

• How are commissioning teams constituted and organised? How does this impact on evidence use?

• Who is seen as holding expertise and insight in relation to ethnic diversity and inequality? Why?

• To what extent do PCT commissioning organisations have explicit models, structures, processes and objectives that support the mobilisation and utilisation of evidence? Do these consider ethnic diversity?

• In what ways does managerial behaviour support and encourage, or deter, the explicit consideration of research evidence relating to ethnic diversity and inequality within commissioning teams?

• In what ways do the available infrastructure and resources support and encourage, or deter, the explicit consideration of evidence relating to ethnic diversity and inequality within commissioning teams?

• How do national, regional and organisational policy priorities inter-relate to shape the mobilisation and utilisation of evidence in this area?

Although the data collection activities were nominally undertaken as part of either the strategic-level or the operational-level case studies in each study site, in practice there was overlap in the material generated. For instance, many of the interviews conducted for the operational-level case studies also provided rich insights into the wider workings of the organisations, whereas observation of strategic-level meetings revealed information not only about organisational priorities and structures but also about how individual actors might exert their own agency in responding to them. Therefore, although the findings are organised into two chapters – Chapters 4 and 5, with the current chapter focusing on organisational-level structures and cultures – we draw across the range of data generated as appropriate.

The case study work provided confirmatory evidence in support of many of the themes highlighted by the key informant interviews, and gave more detailed illustration of how these factors played out within the operational settings of the three PCTs. In addition, this stage of the project provided further insight into how commissioning work is achieved in practice, and in particular the factors operating at different levels to shape and constrain the use of research and other forms of evidence in commissioning in general as well as in relation to ethnic diversity and inequality.

We therefore take the key themes highlighted from the key informant interviews in Chapter 3 as a starting point and use summary tables to illustrate the ways in which the case study materials support or refute each of these, providing selective commentary to highlight additional themes not previously highlighted by the key informants.

Assessing health needs and identifying gaps

Case study respondents in all areas identified needs assessment as a core element of commissioning, especially when public health was closely involved in commissioning work. We found several examples of focused needs assessment work as well as investment of resource, particularly from public health, in the more holistic JSNAs. Population-level demographic and health data were important components of needs assessments, as were service use data, although the latter seemed to feature more clearly in focused needs assessments than JSNAs. There was also evidence of community-level and service user consultation feeding into needs assessment documents.

We also found examples of very detailed work that brought together local and national data and reviews of published research to build a detailed picture of local need in the context of the wider evidence base on a particular area. These pieces of work often seemed to be prompted by a particular individual’s interest and were often supported by additional resource. Furthermore, there were many examples in which such analysis would have been helpful but was not undertaken.

In terms of assessing health needs across different ethnic groups, as already noted, this was often severely hampered by an absence of population- or service-level data disaggregated by ethnicity. The lack of such basic descriptive data was reflective of the low organisational priority given to understanding and addressing ethnic inequalities, suggesting a mutually reinforcing cycle. However, the lack of data was clearly recognised and felt to be frustrating by some commissioners: ‘We need to get our data gathering around ethnicity improved. You can’t redesign or reprioritise services if you don’t know who’s coming through the chuffing door’ (PCT public health practitioner/commissioner).

The case studies also confirmed that good minority ethnic representation was often not achieved in community- and service-level consultations that were intended to inform needs assessments. For instance, the Maternity Service Liaison Committee in both case studies in which it was examined had struggled over a long period of time to ensure the engagement of minority ethnic women.

However, there were some examples in which needs assessments included ethnic breakdowns of quantitative data and we also found examples of commissioners initiating a range of strategies to plug gaps and draw in a range of complementary evidence (Box 2). These creative approaches are promising; however, they appeared to be highly dependent on individual skills and interests and were not often shared widely within or outside the organisations.

Furthermore, there were two common areas of weakness. First, there was often uncritical use of ethnic categories. Even in projects that had an explicit ethnicity or equalities focus, we found that the broad category ‘black and minority ethnic’ was employed without any justification and it was rare to find any discussion of why particular ethnic categories had been used or what their strengths or limitations might be. Second was the failure to go beyond basic descriptions of health or service use patterns by ethnic group to explore the factors explaining any observed differences.

Designing service responses and prioritising action

Many respondents noted that prioritisation often took place at a very high level of generality and that there was often a weak link between health needs assessment and the areas that were prioritised for focused commissioning attention. Rather than population health profiles and community consultation evidence, the sources that featured heavily at the prioritisation stage tended to reflect the strong drivers and infrastructure around the quality and efficiency agendas. At the operational level we found benchmarking data on expenditure and quality being regularly used to identify areas that might warrant closer commissioning scrutiny and possibly yield savings:

Some of the other work that I do is on a sort of benchmarking basis around areas that we might have a higher level of commissioning activity in, and we may want to readdress with our providers to look at efficiencies and drive forward change in the ways we’re delivering services, NHS services. So I’m heavily involved in QIPP, which you may have heard of so that’s really about looking at our NHS comparative data or other national benchmarking data, looking at where we overperform in activity terms and overspend NHS resources on secondary care services.

PCT commissioning manager

Similarly, the organisational importance attached to adherence to government policy was reflected in regular use among the commissioning managers who we interviewed and observed of synthesised research in the form of NICE guidance and policy documents:

Yes, it would be the policy, definitely the policy, so it’s very much that overview.

PCT commissioning manager

It’s synthesis of evidence from around the place . . . on the basis of what the literature tells us, and systematic reviews, evidence base reviews, NICE guidance, other guidance from other authorities like NICE and so on, so a whole range of things like that, trying to bring those sorts of things into the commissioning process.

PCT senior public health commissioner

However, as illustrated in the quote in Evidence use across the commissioning cycle on p. 67, commissioners found national policy to be often lacking in guidance on how to shape service responses at a local level. We found commissioners drawing heavily on the experiential knowledge of local practitioners and clinicians, as well as practice examples from elsewhere, for evidence of how services might be shaped effectively to achieve improvements (usually defined in terms of national quality markers and cost saving).

In the context of an innovative reconfiguration of children’s mental health services, we recorded the following comments:

Interviewer: So would that, would you say that that came from the commissioning side of things, or from the provider?

PCT commissioning manager: No, it came from the provider, from the clinicians and from education. You know, coming round the table together and saying can we do anything differently . . . So, the process of bringing people together is stimulated by commissioners, but actually the solutions come from, you know, came from the clinicians.

Drawing in practitioner experiential evidence (sometimes called expert knowledge) happened in many ways, both formal and informal, as well as ongoing and more ad hoc. For example, the early booking work was based within a Maternal and Child Health Planning and Commissioning Group that included senior practitioners from midwifery, health visiting and general practice who were formal group members and who regularly offered their insights into how services were functioning and how new directives from the DH, or local issues, might best be responded to. In contrast, the following quote illustrates a one-off focused effort to access practitioner expert knowledge using external resource:

It appears that we have a considerable number of more people in secondary care mental health services than our comparators, which suggests that community mental health teams are maybe not discharging people as often as they, or as soon as they should, or that GPs are referring more people than other places do . . . We talked to our lead GPs on mental health services a couple of months back, got them in a room with the clinical directors from the Care Trust, had a conversation about so what do we think they could do differently, and it didn’t get us anywhere which was a bit disappointing, yeah. So we’ve, we kind of thought we needed some expert help in, in getting ideas, so we’ve commissioned this company to talk to 20 or 30 GPs about their perceptions of mental health services, the scope for service improvement, and in particular identify areas where we do things inefficiently or we do things that we needn’t and that kind of thing.

PCT senior commissioning manager

Examples from other PCTs of how services had been configured were a popular source of evidence on what service solutions might look like. In some cases commissioners identified regional and national networks that were a useful route to information on how other people were shaping services, but in other cases access to such practice learning seemed to be much more ad hoc:

The other forum I use is the regional commissioning network, so it’s sort of like do we know anything, has anybody else done any work around this. Yeah, we’ve got a good, because we’ve got a children’s regional commissioning network meeting. It’s one of the meetings I do go to, because it is useful for exactly that, you know, so and so’s just done a service redesign and might have a specification that she can share with me and it will . . . you know what I mean, I’ve got a starting point rather than a completely blank page in front of me.

PCT commissioning manager

I think Google is the most rapid way to find out what’s out there and then through doing more research on the internet, unpick that. And it is, it’s literally through Google.

Local authority commissioning manager

Despite efforts to engage patients and the public in commissioning, respondents recognised that service user views were often not gathered early enough in the process but more commonly as part of a consultation process after decisions had already been made, meaning that they had little influence on the process of service design. Consultation with service users on the heart failure pathway occurred after the pathway had been agreed. Within the commissioning group there was recognition by members that they could be criticised if this consultation was not undertaken, but the value of such input was also contested by some group members on the basis that clinical expertise was, in their opinion, the most important factor in the design of the pathway.

Furthermore, there could be conflicts between different types of evidence. For example, one respondent noted that complementary therapies that are not shown to be effective by empirical research nevertheless receive very positive service user feedback, thereby creating challenges to synthesising disparate evidence sources.

In general we found few examples of primary research evidence being accessed and used systematically to inform service solutions. Individual commissioners were found to use research evidence at times, with some respondents mentioning particular researchers whose reports and papers they would regularly access and others identifying particular research studies that had influenced their work, but in general this use seemed to be very individualised. This seemed to reflect the lack of structures mentioned in Chapter 4 and the tendency for evidence mobilisation to be seen as a diffuse responsibility, something that everyone should be doing but with little guidance on what this should involve in practice. However, there were exceptions. We identified a number of more comprehensive and systematic pieces of work in which research evidence was reviewed and synthesised alongside other types of evidence to inform the design of services (e.g. a review of parenting support interventions and a review of self-management approaches).

In keeping with comments from some of the national key informants, there was evidence to suggest that local research could be particularly influential. We observed commissioning groups inviting local researchers to attend their meetings to present their work and taking time to discuss the findings from other local studies. Some respondents also talked about influential research during the interviews, again tending to cite local work most often.

As already noted in Chapter 4, it was rare for evidence of ethnic inequalities to be the prompt for focused commissioning attention. However, there were some examples. For instance, across all three sites there was ongoing public health-led work to address the issue of genetic risk associated with consanguineous marriage. Importantly, this is one of the rare examples in which heightened risk among a particular minority group is actually reflected in the overall level of a key national outcome indicator – infant mortality – although it should be noted that the commissioning response was considered to be inappropriately narrow by some local stakeholders. Another example was late presentation for diagnosis of human immunodeficiency virus infection in black African men, an issue that had been flagged up by the specialist provider service and taken on by the commissioner as an area needing development.

We also found examples in which commissioning attention became directed towards the needs of minority ethnic people when their use of health services was perceived to be inappropriate or problematic. In the absence of routine monitoring of service use by ethnicity in our case study sites, it often appeared to be provider intelligence that prompted commissioner attention:

I mean the Slovak community suck up our health visiting resource in the north of the city, and we know that, but there’s nothing you can do about that, because they have particularly high needs. You know, so it’s not like we can sort of say well . . . well you can’t say anything, can you, you’ve just got to respond to it. But to try and get some of the information to truly understand it, because they’re such a transient population it’s almost like they’re not still enough long enough to know whether that’s what we’re counting or if we’re double counting, if we count the move there, and it’s just, I don’t think we’ve got a clue picture of it at all.

PCT commissioning manager

Occasionally, evidence brought by third-sector or community organisations of unmet need among minority ethnic groups had also been the prompt for commissioning action.

In terms of the shaping of services, it was also rare to find commissioners drawing on research or other evidence relating to ethnic diversity and inequality. In some cases commissioners seemed simply to overlook this dimension, viewing service users as a homogeneous group and adopting a ‘one size fits all’ approach to specifying services, as clearly recognised by some of our respondents and confirmed by our documentary review of multiple service specifications:

I think – this is how I perceive what we’ve commissioned in the past, is a sort of flat service assuming that everybody’s going to access it in the same way, not particularly looking at other groups and whether everyone does have equal access once you’ve set it up.

PCT senior commissioning manager

In other cases, commissioners seemed to recognise the potential relevance of specifying the service in relation to different needs, but lacked access to the required evidence to inform a detailed specification. In still other cases, however, there appeared to be a withholding of detail that could have been specified on the basis of available evidence. Although this tendency to limit detail in service specifications was not peculiar to ethnicity, the lack of detail is likely to be particularly problematic when providers lack other sources of guidance on how to ensure that diverse needs are met. It was particularly noticeable that, even in areas of service development where there is strong evidence of both important ethnic inequalities and effective interventional approaches that might be specified by commissioners, such as diabetes management, detail on ethnicity remained lacking.

Practitioner expert knowledge seemed to be less regularly drawn on to inform service responses relating to minority ethnic needs than to inform services more generally, and there were signs of important missed opportunities in this regard. In particular, third-sector organisations that might have important insights were not generally routinely included in commissioning forums, and respondents from such organisations talked about struggling to find routes to get their evidence into commissioning processes. The exception to this was the Innov8 research case study, which specifically focused on the contribution of BME practitioners and included input from third-sector providers. However, this issue had clearly been identified as a gap in the current processes of generating understanding of need and identifying service responses and it remains to be seen whether this project can have an impact beyond the individuals directly involved.

It was also rare to find examples of commissioned research or insight work focused on identifying approaches to improving services for minority ethnic populations, with these tending to focus more often on minority communities themselves and being restricted to the needs assessment phase.

We found few examples of commissioners drawing on published research evidence on ethnic diversity and inequality to inform service designs and specifications, but there were some examples of this and in other cases commissioners clearly wanted access to better evidence on effective interventions. One public health commissioner was particularly keen that the current project should produce evidence digests as part of the package of tools as she expressed great frustration at not being able to easily access evidence on successful interventions for minority ethnic populations:

What you are challenging me with today is about how do we use that [evidence], but if the evidence isn’t there, or it’s not sufficiently orientated to me or my services to which I have some remit, then there’s a disconnect, a complete disconnect, and how can we bridge some of that?

PCT senior public health commissioner

Monitoring and evaluating services and service changes

As already noted, we found that commissioners regularly accessed locally and nationally produced performance indicators relating to spend and quality to monitor the performance of the services they commission:

You know, we’ve just had a meeting with XX, the contract manager and everybody, and basically really beat them up about C-section rates and said you’ve got to do something . . . and we are going to work with you on it and we’re going to point out the fact that we’re benchmarking high on this and we’re not happy with the rates and we want to see a reduction.

PCT commissioning manager

There was also some evidence of commissioners drawing on user and carer experience data to assess the quality of services, although this was clearly not completely embedded and varied in terms of detail and frequency. Further, it was not always clear what action resulted from reviews of this type of evidence. For instance, the Maternal and Child Health Planning and Commissioning Group in one site funded an annual survey of maternity users by an independent local group and the findings of this were shared and discussed, but it was more difficult to see how these were brought together with other evidence sources to really evaluate the current provision and feed into service developments.

It was rare to find commissioners generating or accessing any detailed process information on how services function, or undertaking any kind of process evaluation, even when detailed redesign work had been undertaken. In the A&E case study, one area of activity involved the analysis of routine data sets to identify individual patients who were high users of A&E departments followed by individual GP practices identifying and introducing a range of initiatives aimed at reducing usage (e.g. leaflet campaigns and recall of high users). After a period of follow-up, data on the overall trend of A&E usage across different parts of the city were presented to the unscheduled care network. Although the data suggested a smaller rise in A&E use in those areas of the city where there had been these new initiatives than elsewhere, there was agreement that no causal link could be drawn. There was no investigation of how the interventions had operated in practice. This meant missed opportunities to generate important local implementation evidence that could inform further service improvement, a limitation recognised by some of the managers involved in the work. We did identify a number of external evaluations that had been commissioned to examine particular programmes of work or clusters of interventions, although in some cases local stakeholders raised questions about how transparent these had been and whether commissioners were really interested to learn about things that did not work well or rather just wanted to hear the so-called ‘good news stories’.

In the main, neither quantitative nor qualitative sources of evidence on service performance were broken down by ethnicity. It was rare to find that commissioners had included ethnic-specific KPIs or used Commissioning for Quality and Innovation (CQUIN) to define areas of service improvement for minority ethnic groups, through which the generation of ethnic-specific monitoring data could have been prompted:

And in the health visiting specification we haven’t got anything, any, we haven’t got any kind of KPIs around ethnic inequalities, so you know, we may, or may not be entirely following through on, you know, on these things in the areas where we could.

PCT senior public health commissioner

It was more common for community and third-sector organisations than NHS trusts to be required by commissioners to record and report service-level data by ethnicity, but even these data were not often drawn on to inform service improvement. Some respondents felt that the general failure to evaluate service modifications was a particular problem in relation to interventions targeted at minority ethnic populations, many of which were funded by short-term pots of money. Respondents identified important missed opportunities to develop local learning and confidence about how to address minority needs. They felt that the lack of such evaluative evidence – which might show indications of progress made, even if bottom-line measures took much longer to impact – tended to perpetuate unhelpful perceptions that ‘nothing works’ and communities are ‘hard to reach’.

However, it is again important to note those rare instances of good practice in which particular commissioners had taken the initiative to undertake service evaluation and monitoring work with a particular focus on minority ethnic communities and service users (Box 3).

Demand for evidence

The case study work suggested a number of factors that operated to produce a low demand for evidence on ethnic diversity and inequality within the commissioning organisations that we studied. In many cases commissioners simply did not think about the relevance of considering ethnicity in their work, reflecting the wider marginalisation of this agenda, and therefore did not demand evidence at any stage of the commissioning cycle.

In other cases commissioning staff were aware of the potential relevance of ethnicity, but a range of obstructive attitudes undermined their tendency to seek out evidence. The wider ambivalence towards addressing ethnic inequality at policy and organisational levels was reflected in some individual commissioners who expressed uncertainty about the legitimacy of giving attention to this issue, and questioned whether it would be construed as ‘privileging’ minorities over other sections of the population. Another prominent theme was the fear of getting it wrong, with commissioners opting not to pursue the issue rather than engage in work that was perceived to be complex and sensitive:

People’s awareness of the issues is very variable . . . some people struggle . . . And to be able to write about ethnicity, people can be a bit sensitive about it. Am I writing it the right way? Am I using the right terminology?

PCT senior public health commissioner

There was also evidence that some commissioners made assumptions about the additional cost that they felt would necessarily be involved in commissioning services that took minority ethnic needs into consideration and therefore chose not to demand evidence even of need. This perception was linked closely to the assumption that responses to minority ethnic health needs necessarily involve separate and additional services, rather than recognising the scope for existing services to be made more responsive:

There’s a mindset that says if we do anything for BME communities that’s on top of what we already do, rather than what we already do should incorporate the needs of BME communities.

Local authority manager

So I always feel there’s this ginormous tension between how do we do the best for the most, against balancing up how much do we then pull off to spend a proportionally more amount of money and time targeting a group which they might have greater needs, but it might take three times more money per head to actually get the same numbers of people through the door, and you’re always measured then on numbers through the door.

PCT public health practitioner/commissioner

We found that in some cases commissioners assumed that data or evidence were unavailable rather than exploring whether this was really the case or putting in place measures to improve the data that were being collected. Importantly, provider organisations noted that they often had data and evidence that were not demanded by commissioners. There were also assumptions that a general focus on health inequalities would mean that ethnic inequality was taken care of:

I would like to say it’s core business, you know, mainstream, I mean health inequalities certainly is and we certainly have a, you know, fairly strong understanding, I think I would say across the board that a dimension of health inequality is ethnicity. So, I would think that everyone round that table would have quite a developed understanding of that. [For instance] with the CAF [Common Assessment Framework] we focus on vulnerable families. We’d know that there would be more families from Pakistani, Bangladeshi, African Caribbean community with CAFs so you would be addressing that vulnerability, but we’re not looking at it [ethnicity explicitly], and to be honest I don’t know if they would have the data where they could tell us that anyway, you would hope they might do.

PCT senior public health commissioner

Finally, we found that some commissioners made assumptions about other members of staff – particularly E&D staff, but also sometimes staff of a minority ethnic background – being responsible for ensuring adequate consideration of this agenda, again reflecting the fact that attention to ethnicity is not part and parcel of understanding and meeting population health needs.

Given the wider organisational contexts that did not reward good work or sanction work that overlooked this dimension, there were few challenges to attitudes and beliefs that undermined a demand for evidence on ethnicity. Indeed, a perception among individual commissioners that focusing on ethnicity was not perceived to be relevant among their managers could reinforce their belief that such efforts were illegitimate. Further, a general lack of guidance in terms of what commissioners might be expected to do to ensure adequate understanding of, and responses to, ethnically diverse needs, and the lack of sharing of good practice within and between organisations, appear to perpetuate these attitudes and beliefs. Where national drivers did exist for more concerted work on this agenda, they were found to be important prompts. For example, the equity audit carried out as part of the early booking case study was prompted by a recommendation in Maternity Matters. 100 Similarly, the need to address under-representation of South Asian coronary heart disease patients in cardiac rehabilitation services was highlighted in NICE guidance and prompted the local health needs assessment work observed in one site. The Equality Delivery System had also acted as a national driver that highlighted many gaps in the understanding of health needs for minority ethnic communities, and was actively engaged with in two out of the three sites.

Accessing and sharing relevant evidence

The case study work suggested a number of factors operating at the micro level that were important in facilitating or constraining access to relevant evidence on ethnicity within the commissioning arena.

A key theme here was the centrality of the relationship between commissioners and providers. We found that, in many instances, accessing relevant evidence to inform commissioning action was highly dependent on a co-operative commissioner–provider relationship. In the case of large NHS provider trusts, commissioners could find it difficult to enforce the provision of necessary information within the context of large contracts with many competing demands (Box 4).

In some cases, providers were observed to advocate on behalf of minority ethnic needs, bringing evidence to commissioners to challenge the omission of issues or the misspecification of need:

Here, in XX, even though it’s 90 something per cent black and ethnic minority, in terms of a need analysis for breastfeeding, there isn’t, that it’s so good, the breastfeeding rates, so somebody could say well you don’t need a breastfeeding peer support worker in XX at all, and then we would fight to say no, we do need it, because we know the issues whereby people will stop or people will come out of hospital bottle feeding unless a breastfeeding peer support worker’s supporting them.

Third-sector manager

However, as discussed in Chapter 4, evidence from third-sector providers could also be contested and rejected by commissioners, particularly if it challenged pre-existing decisions, a reflection of their relative lack of power within the commissioning arena.

More generally, we found that some commissioners lacked the time and/or confidence to pursue areas of service development focused on the needs of minority ethnic people and looked to providers for co-operation and support in mobilising the necessary evidence. If not forthcoming, they would invest their energies elsewhere.

That said, there was evidence of uncertainty and contestation around commissioner and provider responsibilities to find service solutions and ensure effective implementation. There was wide variation in the extent to which commissioners worked actively with provider organisations to mobilise evidence of different types in support of improved delivery of services to minority ethnic people. Although some commissioners were clearly instrumental in shaping service responses, others seemed to view finding solutions as beyond their remit, looking instead to providers for this input:

I wouldn’t see it as just up to us to do that [find the solutions], it’s up to the service that’s operating to do some of that work and that development work. There’s a fair amount of evidence out there.

PCT senior public health commissioner

At times commissioners expressed discomfort at raising issues relating to ethnic inequalities, particularly if these related to the behaviour and performance of health-care staff within large NHS trusts, questioning whether it was appropriate for commissioners to ‘interfere’ in these areas. Interestingly, however, we found both commissioning and providing managers who expressed frustration at the unwillingness of the other party to devote time to finding solutions to ethnic inequalities. As the following quote suggests, commissioning efforts to access evidence and inform service development for minority ethnic people will often be overtaken by other priorities unless there is good co-operation from providers:

PCT commissioning manager: We tried to do one [CQUIN] on CAMHS [Child and Adolescent Mental Health Services] . . . we tried to do something around [ensuring] the level of activity was appropriate to the ethnicity profile within the locality team and the configuration but they just wouldn’t have it, they just would not go there at all, it’s just too hard, it was too difficult. Because they can’t achieve it, and I know exactly why, because what it takes is it takes a provider going out there and getting the people in, so it takes a provider taking responsibility for the mental health care of children in the city, instead of providing what comes in through the door and what’s on my waiting list . . . yeah, ‘we need extra resource to do that, it would take a lot of targeting and interventions, there would be a reluctance and there’s a cultural difference in terms of understanding treatment, family therapy and family interventions aren’t accepted by a lot of these ethnic groups’. You know, there was a raft of excuses. So you know, you get to the point where you sort of think well if family intervention and family therapy is not accepted what else are we doing, you know, is there an alternative to family therapy then, that, you know, these groups of people accept so we ensure that their mental health needs are treated?

Interviewer: So to what extent can the commissioner’s role sort of extend to seeking some of those solutions, you know?

PCT commissioning manager: Yes, yes, if you want to drive change, but it’s how hard you want to press some of the buttons and the priorities, the overall priorities because I suppose in CAMHS for me at the minute it’s reducing waiting times . . . a waiting list reduction initiative is a major priority, so therefore looking at things like access for ethnic minority groups is less of a priority, you know what, and that’s awful but it’s the harsh reality around targeting resources, and when I say targeting resources it’s commissioning resources as well as . . . so that’s the tricky one.

A further important theme was the extent to which commissioners and other stakeholders, or evidence bearers, were networked. There appeared to be many missed opportunities for relevant evidence to inform the commissioning process. For example, we found instances in both maternal and child health case studies in which highly relevant local research evidence was not brought to the attention of commissioners or was only discovered by chance. Some commissioners expressed the feeling that they were not part of networks that shared research evidence in the way that clinicians and managers working in provider trusts often were. In part, this may reflect the more generalist nature of some commissioners, but it also seemed to reflect a need for more deliberative inclusion of commissioning organisations within collaborative structures through which evidence circulates, such as Collaboration for Leadership in Applied Health Research and Care (CLAHRC) networks. Evidence and data on ethnicity held by other agencies, particularly local authorities, that could inform needs assessment work were not always accessed by health-care commissioners. For example, in one case study site an interview with a commissioning manager for young people and families revealed that complete self-reported ethnicity data were available for all children and their parents in the region, which had never been used by the health sector to improve its population ethnic profile, which was based on crude estimates. However, this situation seems to be improving to some extent, with JSNAs becoming increasingly collaborative efforts.

It was also evident that there were missed opportunities for sharing within PCTs themselves, with isolated pockets of good practice being common and internally generated evidence not being shared very widely. In one case study site there had been significant improvement over time in ethnic monitoring in general practice, but we could not find evidence of a single case of these data being used by commissioners.

Using evidence critically and effectively

In relation to commissioners’ confidence and competence to use evidence on ethnic diversity and inequality critically and effectively, three important themes were prominent.

First, there was evidence to suggest that unsophisticated understandings of ethnicity and its links to health could lead to partial and inappropriate use of evidence as well as a failure to adequately appraise the quality of different evidence sources. We found commissioners failing to ask appropriate questions of particular evidence sources (such as whether patterns of service use varied within ethnic groups by sex or migration status). We also noted that commissioners could overlook the relevance of some sources of evidence and give undue emphasis to particular pieces of evidence that fitted with their mental models of how ethnicity impacts on health and health-care experiences and/or what constitutes appropriate service responses (Box 5).

Although some respondents clearly recognised the complex and contested nature of ethnicity – for example raising questions in the interviews about the adequacy of ethnic categories or the need to understand the inter-relationships between ethnicity and religion or the role of discrimination in minority experiences – these respondents were few in number. Interviews with many more commissioning staff suggested a lack of reflection on these issues and a tendency to foreground culture and language as the defining elements of ethnicity and to downplay structural disadvantage and discrimination. Furthermore, we witnessed very little open discussion of such conceptual issues within commissioning arenas aside from those that were prompted by the feedback of our own study findings.

Second, we found that many commissioners had low levels of competence in appraisal, synthesis and integration skills. Synthesising evidence from a wide range of sources is clearly challenging and, as noted by the key informant respondents, some significant additional complexities arise when the focus is on minority ethnic health issues. Nevertheless, various tools exist for helping with evidence appraisal and approaches have also been developed for plugging evidence gaps, working with incomplete data and integrating evidence across a range of sources. It was rare to find people who were aware of, and confident to use, such tools and approaches. Individual interest and expertise were the key factors determining whether or not such techniques were employed to make more effective use of available evidence. It was particularly noticeable that E&D leads, who might otherwise champion these issues, often lacked the skills, experience and confidence to mobilise and synthesise evidence effectively.

This brings us to a further key theme, the importance of being able to mobilise evidence in influential ways to make progress on ethnic inequalities. Echoing the observations of some of the national key informants represented in Chapter 3, several respondents in the case study work expressed the opinion that decision-makers demanded a higher standard of evidence when the focus was on addressing ethnic diversity and inequality. Observational work also suggested that key actors could at times draw on a ‘hierarchy of evidence’ mental model, whether implicitly or explicitly, to block action on ethnic inequality. Commissioning managers seeking to introduce a new service or bring about improvements to an existing service generally had to leverage resource to fund the proposed changes. This involved commissioning managers (or sometimes stakeholders from provider organisations or community groups) negotiating for reallocation of resources within a fixed envelope of spend; ‘bidding’ internally for investment (e.g. by making an invest-to-save proposal to a QIPP programme); or perhaps submitting an application to an external source of funding designed to encourage innovation. Regardless of who was making this case, respondents often reported that it was challenging to prepare a strong business case in the face of incomplete local data and very limited evidence on the cost-effectiveness of proposed interventions. The importance of packaging and communicating evidence was clearly important to securing decision-makers’ support for proposals. Some individuals seemed to be much more confident about, and influential in, using evidence in this way. For instance, we found a few examples in which incomplete data had been mobilised effectively by commissioners to gain investment for development work on ethnic minority issues. On the other hand, we also observed a case in which personal clinical experience was used to trump NICE guidance on drug use for African Caribbean cardiac patients and thereby block consideration of ethnic difference within the pathway work. The ability to use evidence influentially also linked closely to skills in conceptualising ethnicity clearly, and appraising and synthesising evidence effectively, as it was common for proposals to be challenged on the basis of issues such as small numbers; representativeness; inappropriate ethnic categories; lack of disaggregation of data into subgroups; questionable transferability of findings to the local context; and insufficient detail on the underlying causes of observed differences, and whether these causes were really something that health-care commissioners could and should do something about.

Leadership

The research data indicated that strong leadership on ethnic inequalities was a key enabler, especially in ensuring that attention to ethnicity was mainstreamed and good work was prioritised and shared across the organisation.

It doesn’t matter how brilliant, innovative, courageous, forward-looking operational folk are, they can only make a difference in a small corner of the world. If you’ve got good leadership then there’s an opportunity for those innovative beings to flourish and for what they’re doing to be extended into other areas of the organisation.

Third-sector senior manager

As earlier sections of this report identified ‘silo working’ and a lack of knowledge-sharing or practice-sharing across and within NHS organisations, it was key to have senior guidance that not only recognised ethnic inequalities in health as a major issue but also facilitated joint work and goal-setting across departments. This was particularly key in information-sharing, as human resources, engagement officers, service providers and public health all had useful evidence on ethnicity. And awareness of different data sources, and the signposting of relevant information from disparate departments, requires input from managers with a strategic role across all of these areas.

Some respondents felt that having leaders who personally empathised with and fearlessly championed the agenda was a key enabler:

If you’re a decision maker but you, say, have an adopted black son or a daughter and that son or daughter goes through racism, discrimination, unfairness in society, then that decision maker is actually affected by that because there is a link. What makes him or her change their views on fairness in the workplace is because there’s somebody at home reminding them about those things that are happening. But if you don’t have anybody like that at home or in the workplace, which often aren’t there, then you become in a very bubble world of fairness that exists, but the experience of people who are visible minorities and women and gay people and others is completely different to the decision makers.

Strategic health authority senior manager

This perception was echoed by those participants who described how a new chief executive had changed workplace culture on inequalities by being open about his own disability. This openness legitimised attention to this and all other areas of potential disadvantage, making them visible within the organisational culture. Indeed, one of the key factors in the Innov8 Charter was to promote diverse leadership for this very reason: a sense that people from a range of backgrounds drew on different, marginalised experiences, away from the ‘bubble of fairness’, and that different experience was the most important thing to bring to leadership roles: ‘There’s no point recruiting, you know, different leaders, if what you’re saying to them is we expect you to behave like us, and we expect you not to share what makes you who you are’ (PCT senior manager).

The Innov8 programme also argued that there was a strong business case for increasing the diversity of leaders, highlighting the ability of leaders with different backgrounds to consider different solutions to problems, and offer more effective solutions by being able to better understand and empathise with disadvantaged communities.

However, respondents also expressed the feeling that leadership on this agenda did not need to come solely from the senior level but was essential at a range of different levels to maintain project momentum through the many challenges:

It comes down to leadership. I don’t mean just necessary chief executive or whatever, but you know if you get, if you get a strong public health group, or in some cases it’s a strong patient and public involved PPI [patient and public involvement] lead, it’s a strong character that knows the importance of this stuff and will rattle cages to make sure that it gets done.

DH senior manager

Committed individuals and dedicated staff

The most critical enabling factor observed during the research project was the role of individuals with a deep understanding of, and commitment to, the race equality agenda. Regardless of seniority or role, these individuals became significant drivers for change. Sometimes these individuals were from external third-sector or community organisations, but often they were internal staff with a specific E&D remit (particularly E&D leads based within the PCTs): ‘The equality teams tend to be very passionate, doing it for their personal, moral, you know, values’ (commissioning group chair).

The E&D leads, either in provider trusts or PCTs, were often the lead actors in the good practice examples that we documented. Furthermore, our observations on the implementation of the Equality Delivery System in two out of the three case study sites confirmed the central role of effective E&D staff in making the Equality Delivery System productive. The Equality Delivery System example explicitly demonstrated, across each of the three case study sites, that those organisations with the most E&D staff produced the most in-depth assessments, drew from more sources of evidence and had the best engagement processes. It was also evident that when E&D leads were placed at more senior levels/bands they gained greater autonomy, allowing them to allocate their time more dynamically to issues that they identified as being critical, even in those organisations that generally provided little direction on important equality issues. This finding supports the recommendations of the Competency Framework for Equality and Diversity Leadership (a strategic document produced as part of the Equality Delivery System), which call for E&D roles to be placed at senior levels/bands.

At the same time there was some evidence that having specific roles and responsibilities for equality (or, ideally, for minority ethnic health issues in particular) can be a powerful organisational enabler. These roles permit networks, deep(er) engagement and specific skills to develop:

Often PCTs had particular race equality leads, and I think having somebody with that remit in their job title was really important, and a lot of innovation and good work, and it’s often about relationship, isn’t it, so having somebody you know to link in with works for the community group and works for the lead as well in the PCT, because over time they build up these sort of relationships with people, so they know about an organisation, they know what they’re trying to achieve, and they know what they’ve been achieving year on year, so at least there’s the dialogue going on.

Third-sector senior manager

Yet another key enabler observed was having staff with a community and/or equality role embedded and well networked within the organisation, rather than having such work contracted out to external groups or consultants:

The community development workers . . . were placed within the primary care trust rather than the voluntary sector, that has helped, so they are based with the PCT there, so they are a core part of the group. I guess they’ve been able to engage with the strategic staff a lot better than some of the other areas who might have been outside of the PCT and outside of health services.

Third-sector senior manager

Many of our research respondents also felt strongly about the need for the workforce of commissioning organisations to be ethnically diverse and to reflect the communities for whom they made decisions. Again, this was felt to increase the likelihood that commissioning staff would understand the need for dedicated work to engage with ethnic diversity and inequality and thereby prompt the demand for evidence production and utilisation:

That’s why having an organisation that reflects the communities that we serve is a very, very important part of it, because if they reflect the community they serve then people who are actually at the decision making process know what it’s like to be a woman, know what it’s like to be Black, know what it’s like to be a gay person. That thinking, that experience is brought into the decision making of what is important, what are the priorities.

Strategic health authority senior manager

Supportive and productive networks

As well as having committed staff within commissioning organisations, networking was identified as an important enabler. In particular, organisational investment in communities of practice – particularly to support and connect E&D and other staff who can otherwise become isolated when working on this agenda – was felt to be very helpful. The value of communities of practice was demonstrated most clearly in the case study work, from which a powerful network of E&D leads was identified in one of the study sites: ‘I think that’s one of the things I’ve really really found useful, and I don’t think I’ve realized how much until we’ve not met for a while, because it’s quite an isolating job being head of equality’ (commissioning group chair).

Previously, the individuals in these networks had had few opportunities for joint working. However, by setting up regular meetings they were able to raise common concerns and scale up solutions that had worked in one provider trust across the whole city. This led to a common approach for equality monitoring of complaints and to the sharing of resources for community outreach events, saving a great deal of time and duplication across provider trusts.

Communities of practice were also clearly beneficial for commissioners wanting to find solutions to equality-related issues. Here, informal networks with other commissioners, including those working on other clinical areas in other PCTs, had facilitated information-sharing and greater awareness of successful interventions:

We used to have regional networks until very recently . . . I wouldn’t say it’s perfect, but yes, I could call on colleagues and say ‘have you done anything on; it doesn’t look like our service is hitting this community. I know you’ve got a similar community. What have you done?’

PCT senior public health commissioner

Importantly, however, national, regional and organisational support for such networks is currently in decline. Nonetheless, as well as these formal/institutional networks, informal networks and interpersonal relationships can also be important enablers. These informal networks, both within and between organisations, ensured that commissioners were well informed about issues and sources of information. They also ensured that commissioners had ‘allies’ who they could draw on to increase support when tackling minority ethnic issues that would otherwise have been marginalised with senior decision-makers:

I have to be honest with you, individual relationships really matter. I have seen a lot of decisions are made in corridors and at tables, I’ve been a part of those, I’m sat outside saying look I need your support on this when we go in there and it’s happened, not just because of the relationship, it’s because they know that it will benefit us, but we have had a pre-meeting before going into the meeting so you’re more privy to the stuff than before.

Local authority senior commissioning manager

Although often personalised, another aim of the Innov8 programme is to foster and support networks between ‘diverse’ members of staff and thereby provide opportunities for such individuals to take the lead on small pieces of work for the first time. This was the case in the Innov8 research project in which the leader of the work had gained opportunities through Innov8 to work directly with the chief executive and senior project managers for the first time.

Incorporating ethnicity into national agendas and routine processes

As previous chapters have noted, ethnic inequalities are rarely a major agenda within the NHS. However, we found that progress on this agenda was more likely when actors engaged with core priorities and processes, and sought to integrate attention to ethnic health issues within these other core areas. This was particularly evident during the period of this study, when budget cuts and efficiency challenges led to little ‘new’ commissioning. For example, much of the work observed in the operational case studies followed the redesign of existing clinical pathways, providing an opportunity to ensure that services were being equitable. One good practice example involved a project for enhancing stroke awareness that had grown from a national agenda (promoting the ‘act FAST’ message) and tailoring this message to meet a local need amongst minority ethnic communities.

Meanwhile, compliance with legal duties was an issue that was often raised by participants to ensure that the NHS was paying due regard to equality issues. By drawing on the nine protected characteristics in the Equality Act 2010,99 the Equality Delivery System was an important part of the NHS response to meeting its public sector duty, with Equality Delivery System outcomes leading to Equality Objectives set by each PCT. However, the Equality Delivery System process demonstrated that evidencing disadvantaged service delivery amongst one or more minority groups was often difficult to achieve because data on service use and users’ experiences were often not disaggregated by ethnic group. This process was nevertheless positive in that it highlighted gaps in the data and prompted the setting of targets to improve data collection and disaggregation in each of the sites for the next iteration of the Equality Delivery System.

Elsewhere, commissioners and activists had to be creative to identify suitable mechanisms for enhancing attention to minority ethnic issues. Where services were not meeting the needs of minority ethnic users, the QIPP programme could be argued as delivering a poor-quality service to these groups. It might also be argued as leading to potential inefficiencies if unmet need was likely to have been leading to late diagnosis and treatment. Indeed, because cost saving was a common concern for commissioning organisations during the period in which this research study took place, it was good to see that some individuals had had considerable success by acknowledging the need for efficiency and developing business cases that successfully demonstrated how a better understanding of the needs of minority communities could lead to more efficient resource use:

I worked with some of the managers there, listen to what they had to say, what their reservations were, what their priorities were, but then after observation I worked with them to show them how we could fill those four beds or not fill those four beds, whatever the priority was, by ensuring that we’re doing the equality proofing, because we can prevent people from filling those beds so it will cost you low, that’s why we need to do this. So it’s very important then to relate it back to what is meaningful to other managers who may not have equalities as their priority.

Third-sector senior manager

Another scheme that had been used successfully to address ethnic inequalities was the Quality and Outcomes Framework (QOF)102 payment by results system for primary care. One PCT had used a local QOF outcome to successfully encourage GP surgeries to improve the ethnic monitoring of their patients. In another example one GP surgery that worked specifically with asylum seekers and ethnic minorities persuaded the PCT to develop a QOF indicator that would allow them to meet the specific needs of their service user populations:

So they managed to negotiate with the primary care trust about, back in 2004, 2005, for a modified QOF . . . where payments were made for them delivering services better aligned for them, so providing TB [tuberculosis] service screening, or providing new entrants screening, and the points were awarded for that, rather than our standard measures of cancer care and what not, which were less common in this group.

GP

Here, a provider had worked with the commissioners to ensure that they were able to provide appropriate additional services without the need to specify, or tender for, an additional service, an arrangement that was beneficial to both parties.

In both cases improving the monitoring of access to, and outcomes of, services disaggregated by ethnicity was part and parcel of service improvement. As such, this illustrates the importance of incremental and integrative approaches to improving the evidence base for commissioning.

Looking to the future, several respondents suggested potential opportunities for embedding attention to ethnic inequality within emerging commissioning structures. In particular, there were hopes that commissioners would be more accountable to local communities through the health and wellbeing boards, and that stronger JSNAs and more co-ordinated work would help to address the wider social and economic determinants as a result of the move to local authorities of public health. At the same, however, they noted that a national policy context that had been further weakened could continue to undermine progress towards a more enabling environment in the future.

Provider–commissioner relationships

As discussed in previous chapters, there was substantial evidence of uncertainty and contestation around the role boundaries of, and relationships between, providers and commissioners. Many respondents expressed the sentiment that relationships were difficult to manage and tended to undermine progress towards better services: ‘The model is an essentially market model, which is that you split the purchaser and the provider apart’ (third-sector manager and analyst).

However, many felt that the most productive work was achieved when relationships between commissioners and providers, especially the larger provider trusts, allowed both organisations to input into service specifications and outcomes. Provider staff – particularly clinicians and practitioner managers – were concerned with more than simply delivering a contract; they often had a genuine desire to improve equitable service delivery and held invaluable knowledge and front-line experience of feasible solutions:

I have really good links with clinical colleagues delivering the services that we’re talking about, so it’s not like I just sit in a room and say ok, this is all the data, let me just think up a service. It isn’t like that. It’s very much a partnership approach to a lot of this with clinical colleagues, with providers, with other stakeholders. I jointly commission quite a lot, particularly older people’s mental health services, so myself and a colleague in the council sit down together and jointly put together commissioning plans. Again, they bring different evidence to the table; they see things sometimes from quite a different perspective which is really quite refreshing sometimes.

NHS senior commissioning manager

Respondents were also sometimes concerned that pressure on commissioners to act as impartial buyers of services in an open market system limited the opportunities for co-working with potential providers to develop better solutions. Case study respondents and the good practice examples detailed several situations in which deep relationships between commissioners and providers had led to innovative services being trialled, such as those in mental health, thereby generating important new evidence of what works best to meet diverse needs: ‘That’s what I think the job of commissioners is, and commissioners are there to help the market, and then to help build the market’ (third-sector manager). This was especially apparent when community-based service providers that worked with minority ethnic communities had been commissioned for targeted services, particularly in mental health.

Clinician buy-in

Getting clinician involvement in all stages of the commissioning process helped strengthen the acceptability and adoption of new and revised services. Clinicians, especially GPs and consultants, were seen as having a large degree of autonomy. They also preferred to take direction from other people with a clinical background: ‘I think if you come from primary care, so again it’s almost like coming from within, and you’re trying to sell the package back to your peers, there’s much more of a buy-in there, really’ (GP).

Specific examples raised by respondents around ethnic monitoring in primary care emphasised the importance of getting clinicians to understand the need for attention to be paid to minority ethnic health issues. Again, all of the examples of good practice that we documented involved teams of commissioners and clinical staff or managers. By integrating both ‘sides’ during the service planning and development phase, they were able to ensure that both understood the issues and the need for interventions. This was also recognised by respondents as a critical part of the successful commissioning process:

There was a combination of the consultant, the, not consultant, medical director, being able to trek his way around the practices, on a peer basis, to sort of push them, you know, ‘this isn’t good enough for us, is it’, sort of thing rather than it being a big stick from somewhere else . . . If you can actually get general practice to see it as ‘our problem’, rather than ‘you’re telling us to do this, but we need more money’, it’s a different world.

Third-sector senior manager

Respondents speculated on the likely prospects for evidence-based commissioning for minority ethnic populations once GPs led the emergent CCGs. Our respondents were generally doubtful that GP commissioners could, or would, take any clearer action on ethnic health inequalities in the near future. They expressed concern that many GP commissioners lacked the necessary skills and experience to engage with relevant sources of evidence. They were also concerned that the immediate concern of GPs would be with the transactional aspects of commissioning and that they would have little time for transformational work. Meanwhile, concerns were expressed that GPs might have low levels of engagement, and poor relationships, with local authority and third-sector organisations. Efforts were under way at the time of this study by champions for this agenda to engage with the new commissioners and to seek to increase their understanding of why it is important and fits closely with their own priorities for better-quality patient care. Furthermore, there were signs that some commissioning GPs’ professional identities, clinical expertise and awareness of local needs might actually help enable them to bring about positive change.

Researchers/academics

There were several examples cited by key informants in which researchers had contributed to commissioning by providing evidence or local research on minority ethnic health issues. However, such work had been most productive when academics were well known to the service group using the findings and were prepared to engage in person:

If academics come along to talk about things, I think people do sit up and listen in a way that perhaps someone else just sort of saying you know, ‘there’s a paper here that says we should do this’, is less, is less powerful.

Public health observatory senior manager and analyst

Professional networks to share evidence between researchers and commissioners, such as CLAHRC networks, were active in each of the study sites. However, respondents had varying degrees of exposure to evidence through these networks. Several respondents noted that evidence was most useful when packaged in brief, easy-to-read formats. They made it clear that they did not have the time to read long academic journal articles or conduct extensive literature reviews.

Collaborations were also most productive when academics had made the effort to reach out to relevant service groups, explain their research in person, make links to actions and possible interventions and establish longer-term relationships to allow a process of inquiry to develop. For example, in the vitamin D mini-case study (see www.eeic.org.uk/mcs/vitd), personal networks with clinicians had not only helped identify the deficiency but also led to subsequent local qualitative research with Somali patients. This revealed dietary patterns that were compounding low vitamin D intake.

User and community involvement

Although user and community engagement is a strong and increasing agenda across the NHS, ensuring representation from across minority ethnic groups was a significant challenge. Engagement worked best when it was an integral part of the whole commissioning cycle, rather than taking the ‘tokenistic’ approval of plans for service improvement that had already been completed. One good practice example on stroke awareness involved engagement from the very start of the process to identify how best to develop messages specifically tailored for minority ethnic communities. This example used a ‘social marketing’ approach at the start of the process. This ensured that specific, evidence-based, solutions were considered from the outset:

I mean a good example where things have worked well has involved social marketing and insight work with communities, so we understand what the issues are for them, what the barriers are to using services are, what their views about health are and so on.

PCT senior public health commissioner

Respondents, particularly those from third-sector organisations but also many commissioners, noted the risks of engagement ‘fatigue’, in which the same well-known people from particular communities were asked for input on all of the service redesign work under way. Cross-sector working in this area was rare, but very successful when it was carried out, minimising resources and frustration from participants:

There’s not one method to talk to everybody. You have to build relationships with people . . . But I think we need to do things differently in terms of jointly doing engagement. So rather than the organisation A, B and C all doing it differently, it may be that A, B and C should do it collectively, and have a database of what you learn shared between three of you. So rather than certain groups being bombarded with A, B and C, they go in one. Because if there is fewer organisations, or organisations with less capacity, you can’t be seeing all these organisations who wanted information from you, who in your experience have done nothing with it.

PCT commissioning manager

In addition, wide cross-sector collaboration on engagement brought unexpected benefits to commissioners in different organisations:

The fire service spoke at one of our consultation events around health . . . but he said the most important thing for him is community engagement and the cross-sector working. Usually you wouldn’t expect for somebody who’s doing a health consultation for the fire service to be there, but he does it, so you know putting in fire alarms is a prevention of health . . . trying to prevent people from smoking would actually have an impact on their health but also actually stop them having a fire.

Third-sector senior manager

However, first commissioners needed to understand the benefits of including evidence from consultation with minority ethnic groups. And, as with providers, the power relationship between commissioners and community groups needed careful consideration. Engagement was clearly most useful when it had a constructive focus, and for this to happen commissioners needed to be open and not defensive:

We arranged for about twelve, maybe fourteen, local community groups to host a meeting with four or five commissioners from elsewhere in the country . . . That, for the majority of commissioners who participated was a life-changing event, because for the first time they didn’t feel they were going to meet with local communities to defend what they’d been doing, they didn’t feel they were going there to be attacked for what they’d not been doing, they didn’t feel that they were going there and people were going to be asking for loads of money that they didn’t have – it was just an opportunity for them to listen and to hear. The impact of that was that when they got back to their local areas they set up similar ways of consulting with local communities.

Third-sector senior manager

Yet to establish these productive engagement opportunities, considerable investment needed to be made in establishing relationships with groups who actually understood the commissioning process: ‘So yes, it may want a time commitment, consulting with local communities, building those relationships, but it’s not just a one-off. You build that relationship and that then becomes an on-going resource to the commissioners’ (third-sector senior manager).

This was seen operationally in the Equality Delivery System case study, in which one site had invested a great deal of time and resource in developing an equality group to consult on issues across the provider and commissioner trusts. This investment paid off by providing an established and well-briefed group for Equality Delivery System community engagement, with participants trusting the process, understanding the goals of the group and participating constructively as knowledge bearers. Commissioners who developed meaningful engagement with minority ethnic communities were able to gain evidence on health needs, test ideas for interventions and gain legitimacy for commissioning decisions.

Perceptions from interviews on existing tools

Respondents from the key informant interviews were asked if there were any specific tools or guides in their area of work that they were aware of and/or had already used. They were also asked what formats they would find most useful for such tools and their general perceptions of toolkits relating to commissioning, evidence use and ethnicity.

Respondents were aware of a large number of existing toolkits but, in general, questioned their usefulness. More than one respondent felt that toolkits were rarely used and tended to ‘sit on the shelf’, and many people felt that there were already more than enough (if not too many) available:

People [are] snowed under with toolkits – I think it’s almost like the latest buzz word, oh here’s a toolkit, everything’s going to be OK now.

PCT senior commissioning manager

There are 101 commissioning toolkits around already.

PCT public health practitioner/commissioner

Many others questioned the need for toolkits for commissioning, either because they did not believe that they were useful in practice – ‘I can’t say I’ve ever seen a really good toolkit for commissioning’ (PCT senior commissioning manager) – or because they felt that, particularly with regard to commissioning for multiethnic populations, a deeper level of change and understanding was needed first:

I don’t want toolkits and guidance, speaking frankly with you, that’s not what’s going to change the culture . . . The connection to equality is not through guidance and toolkits; the connection to equality is through people.

Strategic health authority senior manager

I’m not sure that it’s toolkits that we actually need, I think it’s actual people to record the information in the first place.

PCT public health practitioner/commissioner

However, some respondents had found toolkits to be useful and provided guidance on how to ensure that they would be used, in particular stressing the importance of brevity. As noted in the previous chapters, it was unusual for commissioners to have dedicated time to engage with research, especially on what were seen to be marginal issues, and respondents felt that the best tools and sources of information were therefore the shortest: ‘You’re going to get somebody who will say “yes, I’ve got ten seconds to read this” – bang . . . Two- or three-sided evidence summaries which are backed up with full reports’ (PCT commissioning manager).

Additionally, participants emphasised the importance of getting the format of such tools right, highlighting their experience of the importance of optimum presentation to maximise impact:

We spent three grand to tidy it up into a booklet, give the book away, all of a sudden it receives currency around the NHS . . . the work didn’t change, what we did was exactly the same as what had been evaluated before, putting it into a glossy cover, and with some pictures on it . . . gave it currency.

Third-sector manager

[A website] needs to be actively managed, so it’s not just a static portal, but it’s somewhere where people will keep coming back, you’ve got to keep refreshing it.

DH manager

Finally, there were notable recommendations for the content of the tools:

What would work for me almost an FAQ [frequently asked questions] or a questions and answers document about if you’re commissioning in an area where you think you have different health needs which are due to ethnicity, these are the questions you should be answering and asking.

PCT senior commissioning manager

It needs to include a cost-effectiveness bit in it. Because a lot of those toolkits don’t.

PCT senior public health commissioner

Largely these findings mirror the advice provided by previous research in this area, which highlights the importance of succinct evidence, with Brocklehurst and Liabo advocating ‘evidence nuggets’ or short briefings to share information. 103

Examples of the use of tools and resources from case studies

In general, the case studies did not reveal many examples of toolkits actually being used by commissioning staff. Amongst these few examples, in the Equality Delivery System case study there was a process guide that had been developed by the DH, which contained a grading manual that provided some examples of the sorts of activities that would be indicative of each of the four grades. However, several respondents found the guide unhelpful or even confusing, describing it as verbose and the examples as poor, so that there was little evidence of it actually being used during the Equality Delivery System process.

Case study work also revealed other issues with tools and guides. For example, they were felt to have a short shelf life as frequent changes to organisational structures and priorities made them quickly lose their relevance. Some respondents noted that there was often a need for some kind of external driver to get people to take the time to formally use a tool or a toolkit. This was true of the many guides developed as part of the WCC agenda, an initiative that had itself lost momentum even before the recent commissioning restructure. In the maternity case studies, toolkits that had been produced alongside Maternity Matters100 were no longer in use.

Two other aspects of guides and tools were also highlighted: first, that their use varies between and within organisations, so their impact was varied and difficult to measure; and, second, that some organisations customise or adapt tools for their own needs.

Finally, case study work identified variation in awareness of national-level tools and in the tools used in individual organisations. When tools, even nationally produced ones, are used or altered, there was little evidence of feedback to the tool producers or of sharing experiences of using/adapting these with other organisations. There was therefore limited sharing of valuable real-world experience. The tools produced for the WCC agenda were hosted on an intranet site that was rarely used by staff, one respondent noting that, although visible at first (on the main page of the website), the tools quickly became difficult to find, and general awareness of these was low. Another case study respondent, who was not aware of several of the tools suggested by the interviewer, commented, ‘I think these tools are often very useful but they are time-consuming and we only complete them when “required” to’ (workshop attendee).

Identifying audiences

The research findings tended to confirm the importance of viewing commissioning as an arena within which varied stakeholders can make an important contribution, rather than as the preserve of a narrow set of actors formally designated ‘commissioners’. The findings also revealed shortcomings in the extent to which this wider audience of stakeholders – with their wide range of important skills, resources and evidence – were being effectively engaged in the commissioning process. For example, E&D leads often had extensive experience of, and evidence to share on, minority ethnic health issues but were infrequently involved with commissioning. For these reasons the project team decided that tools and outputs should be relevant to as wide an audience as possible, not least to facilitate the inclusion of this diverse range of stakeholders.

Key informant interviews revealed how many of the ‘success stories’ on minority ethnic health had been advanced by ‘champions’, individuals with deep commitment to and understanding of the agenda. Yet the interviews also revealed that these individuals were not necessarily those with power and influence in the commissioning process. We therefore viewed people as ‘champions’, regardless of whether they fulfilled specific roles within NHS organisations or were external ‘activists’. These people were a key resource to empower others and thereby strengthen any opportunities to improve confidence and understanding of the commissioning process. Tools for this group were focused on building on their own experience, expertise and commitment by helping them draw from the skills and resources of other actors.

Senior members of staff, especially chief executives or board members of provider trusts, PCTs and CCGs, were also seen to be a key target for tools as our research generally showed a lack of senior commitment and understanding of ethnic inequalities in health. For this audience, tools needed to be especially brief, quickly make a strategic case for mainstreaming attention to minority ethnic health and link this into wider agendas such as legal duties and QIPP. Given the difficulty of attracting this audience to in-person workshops, it was decided that the tool development workshops should focus on other target audiences at this stage.

Finally, our findings highlighted a lack of depth in the extent of community engagement undertaken by commissioners, with many commissioning organisations taking an arm’s-length approach. Although demonstrating the benefits to commissioners of including community representatives and service users from minority ethnic groups was one important part of the potential solution to this issue, it was also apparent from our work with both commissioners and community organisations themselves that many community representatives found the commissioning process confusing and/or lacked confidence in how to engage. Tools for strengthening community organisations’ capacity to become involved would therefore need to address the current gap between commissioning and community engagement, and ensure that groups had the confidence and skills to provide meaningful engagement so that it would then take a beneficial form for commissioners. However, tools for this audience need to assume little or no previous understanding of the commissioning process, and be promoted through different networks from those targeting NHS staff.

Establishing the scope of potential tools and resources

Drawing on the study findings we identified three broad ways in which the tools and resources that we developed needed to be able to operate:

• influencing (challenging) key actors

• clarifying thinking and raising confidence

• supporting action to overcome challenges.

Format

Feedback from participants had established that tools should be brief and targeted to ensure that they would actually be utilised. The aim was thus to create a linked suite of brief tools that were modular, in that people could select or be guided to the most appropriate tool for their need and follow up with additional tools if further guidance was required. Adopting this approach would also need to include links to tools developed by other groups, to reduce duplication and ensure that the limited resources available to the project team were focused on the most critical gaps.

The project team identified a number of existing guides or toolkits in this area, either on minority ethnic health issues per se or on more general, yet relevant, areas of commissioning. These had been produced by professional bodies (e.g. NHS Confederation, Royal College of General Practitioners), third-sector organisations with a health or an ethnicity remit (e.g. King’s Fund, Afiya Trust) or individual NHS trusts or the DH itself.

Discussions within the team, and examples from other authors, resulted in the identification of a number of different approaches to formatting exercises for the toolkits in addition to those specified in the project proposal. These included diagnostic, evaluative and change management tools for individuals, teams and workflows, in a variety of formats, such as grading exercises, discussion exercises, structured questions and checklists.

Signposting to, and complementing, other resources

As noted above, the project did not set out to generate the resources necessary to cover the huge wealth of issues identified in the project’s research, particularly those that constituted more generic organisational barriers, or those that affected health inequalities more broadly. In addition, scoping exercises had identified a number of ostensibly effective tools and guides that were already available on ethnicity, commissioning or evidence use. As relatively few respondents seemed aware of, or were using, these resources, it made sense to include signposting to these in the new tools developed by the present project.

Therefore, the project team felt that promoting these resources would be useful to commissioning, and integrating the existing resources in the new tools would allow actors to address a wider range of knowledge and skills than could be tackled with the resources available to the project. It was also suggested that the research project website should provide a selected library of resources for commissioners to draw on, which would help them to understand and mainstream attention to minority ethnic health. However, rather than being standalone resources, it was decided that, where possible, the project’s tools should be designed to link directly to other relevant guides.

At the same time, the project team had engaged with a number of different stakeholders who were themselves engaged in the process of developing tools or resources and who were keen to use input from our research project. This was desirable, not only to prevent duplication of activity, but also to ensure that outputs were promoted through more varied networks. Three ongoing tool development projects fall into this co-production category: a tool for completing equality impact assessments being developed by the West Yorkshire CSU (formerly staff from the PCT); the development of a guide for commissioners on the Equality Delivery System by a multidisciplinary team in Luton; and engagement with the DH in which a list of suitable tools for enhanced JSNAs is being populated.

Method and approach

For the tool development workshops a specific range of tools was developed, selected on the basis that they would work as time-limited workshop-based exercises, fall within the expertise of the research team and cover topics not currently targeted by existing resources. On this basis it was decided that feedback on those briefing resources that were not intended to be interactive, such as the ‘Thinking clearly’ guides, would be better collected outside of the workshops.

For the sake of the workshops it was necessary to create exercises for each tool to stimulate discussion, while ensuring that participants with different roles and experiences could work together and anticipate how the tools would work in practice. Fictional scenarios were therefore created for each tool, enabling group members to focus on the utility of the tool within research-based contexts derived from case studies to ensure that they raised realistic issues, particularly those that the tools were specifically designed to address.

Three full-day workshops in Sheffield, Leicester and London were organised in November 2012 to provide opportunities for generating and collecting feedback on draft tools during their development and to increase the likely utility and impact of these proposed outputs.

It was planned for each event to have up to 20 participants, with exercises based on the tools designed to stimulate small group work based on commissioning, evidence use and minority ethnic health issues. It was stressed in the invitation that the workshops would be interactive and would involve draft tools and exercises that would be revised as a result of feedback provided by participants during the day.

In total, six draft tools/guides were selected for presentation in these workshops:

• Sheffield – ‘Making the case’, ‘Service specification’

• Leicester – ‘Stakeholder analysis’, ‘Evidence mobilisation’

• London – ‘JSNA interrogation’, ‘Service specification and improvement’ (revised).

The service specification tool was trialled a second time at the London workshop after being reworked following feedback received at the Sheffield workshop.

Participants were also given a brief overview of all of the tools that the project intended to produce so that they could get a sense of the complete suite of tools and identify any gaps they saw in their coverage. In addition to the six above, this suite included a brief presentation of the ‘Thinking clearly’ and ‘How to’ guides and the co-produced equality impact assessment and Equality Delivery System tools. At each of the workshops the ‘Frequently raised objections’ tool was also presented and used as a guide to completing the workshop exercises, particularly the ‘Making the case’ and ‘Stakeholder analysis’ tools.

Workshop participants

The initial intention was to invite participants to the workshops who represented a wide variety of stakeholders and, by holding events outside the case study areas, explore experiences of participants based in other regions, which might be useful in testing the generalisability of the tools. Each workshop was promoted through a range of channels, including targeted e-mails to key individuals and invitations disseminated through a variety of professional networks.

During online registration for the workshops, participants were asked a series of questions about their current experiences of tools and resources, which organisations they felt provided useful tools and their opinions regarding the most useful formats of such tools. In addition, a number of potential topics and audiences for toolkits were presented and respondents were asked how important each one of these might be to themselves or their colleagues.

In total, 52 people registered to attend one of the three workshops and 38 were able to attend on the day. Table 10 gives an overview of the organisations and roles represented by those registering and attending who completed the online form.

As intended, the participants had a variety of roles and were from a range of organisations, although there was a higher than expected number of people representing third-sector organisations (as either service providers or representing a community or condition) and fewer than anticipated with a direct role as a commissioner. Particular efforts were made to engage with CCG commissioners, a key audience for future tools.

Format and feedback collection

Each workshop presented two draft tools and involved group work exercises based on them. The workshops provided hands-on time with each of the tools and extensive time for feedback and discussion. Each exercise was approximately an hour long, with an additional 30 minutes allocated for verbal feedback, which was collected by project team members acting as facilitators. Facilitators also made notes during the exercises to record how participants were engaging with each tool and to identify any areas in each exercise that appeared unclear.

A written template sheet for comments was also provided, asking participants to reflect on both good and bad parts of each tool/exercise and to suggest improvements and potential audiences. These were collected and transcribed following each workshop. In addition, 45 minutes was allotted at the end of the day for more general feedback on the suite of tools, those parts of the workshop that had worked well and general suggestions for improvements.

General reflection on tools

In the online pre-workshop survey, participants agreed that tools should be made available online, with simplicity, speed and brevity commonly cited desirable characteristics. Respondents also mentioned the importance of having web-based tools that were interactive and easy to navigate but which could be downloaded and printed for use in group situations. Ease of use and non-technical language were also seen as important, to ensure that tools were flexible and useful to a wide audience.

Few respondents were aware of other toolkits focusing on ethnic inequality in commissioning that they would recommend, with ‘None that I feel do the job particularly well’ being a common refrain. And although many respondents mentioned tools or reports with which they had been involved that would be relevant to minority ethnic health issues, none mentioned any involving evidence use or commissioning.

Although the survey question asking participants to rate the importance of developing particular tools had a small sample size, it still showed a clear trend regarding those areas in which more support was felt to be warranted. Figure 4 displays these data, with tools that ‘help find data’ and ‘understand minority ethnic health issues’ having the highest ranking, needs that fit well with the issues highlighted in our earlier research findings.

FIGURE 4.

Importance of developing specific tools: pre-workshop online survey (n = 52).

Most surprising from these results was the relatively low priority given to tools designed to increase community engagement and the participation of third-sector providers and representatives in the commissioning process. Indeed, these were the only two tools for which votes of low importance were recorded. However, our research findings also found a low prioritisation of wider engagement amongst many commissioners, and this finding is probably reflected by a lack of awareness of the benefits and/or importance of including minority ethnic groups in commissioning, or perhaps the belief that there were already many tools addressing this issue, even if they are not currently well used. Clearly all tools have to make a convincing case for their use and have to be promoted to actors who might not necessarily be aware of gaps in their current ways of working. Not all of the tools listed in the survey had been drafted for testing at the workshops, but the pre-workshop survey data helped the team choose tools that either were a high priority or would need to be well promoted to persuade actors that they were useful.

Tool- and resource-specific feedback

Redrafting process

The feedback from the workshops provided a wealth of views on the content and format of the tools and related resources that the project team could use to revise and improve them. Following the workshops, minor changes suggested by participants were made before placing the tools in a complete form on the project website, which was then disseminated to workshop participants. The intention of this process was to show that feedback had been taken on board while allowing a quick turnaround so that participants could examine the tools in depth in their own time and start using them in their own work.

All of the tools were made available with an explicit note that they were still in draft form and that comments and feedback were still being solicited from website visitors and tool readers/users. As many of the workshop participants expressed considerable enthusiasm about sharing the tools with colleagues, and given that a number of potential workshop attendees were keen to feed back comments on the tools, this approach (i.e. early web-based dissemination in draft form) aimed to access a wider audience for critical feedback. A cut-off for further feedback was set in spring 2013 and after this date the tools were revised in light of these contributions.

Generic issues affecting knowledge mobilisation

Key competencies for commissioners place knowledge management centre stage and include critically mobilising and utilising research and best practice evidence; effectively garnering local intelligence and promoting engagement to assess needs; and turning information into knowledge and action for service reconfiguration that improves access, quality and outcomes. 54,55 Commissioners are expected to be transformational rather than transactional, encouraging innovation and ambition to serve those in greatest need.

Our findings confirm that commissioners often work with a ‘mixed economy’ of evidence, piecing together information from diverse sources in their decision-making. 1,34 However, they may lack clarity on how to appraise, weight or synthesise these various sources and there appears to be little active debate on what constitutes good practice in this regard. The absence of such skills suggests that evidence is unlikely to be effectively mobilised to inform commissioning processes and is perhaps more likely to be used selectively to justify decisions that have been influenced by other factors.

In terms of the ‘mental models’ that guide people’s sense-making,67,68 we found awareness among our respondents of the need to use evidence in influential ways, but also widespread recognition that this is not common in practice. The use of evidence to inform transformational shaping of service provision is often constrained by perceptions that limit the commissioning role to specifying desired outcomes that are subsequently monitored. It is less common to find commissioning being seen as an arena in which collaborative partnerships with providers and other relevant stakeholders help decide what outcomes are needed and how these might be achieved (although some commissioners do hold this aspiration).

In addition to these generic characteristics, however, our findings highlight a range of additional contextual factors operating in relation to evidence on ethnic diversity and inequality. These indicate that, although policy-makers may have a crucial role as receptors of knowledge,25,69 sociocognitive models that look beyond technical skills and resources to values, assumptions and worldviews are also important to consider. Our findings suggest that the ways in which individual commissioners understand the nature of ethnicity and associated inequalities are central to how they seek out, appraise and apply different types of knowledge within their work. These specific issues are outlined in the following section.

Mobilising evidence on ethnic diversity and inequality

Our findings indicate that accessing and making use of information relating to ethnic diversity and inequality is generally not part and parcel of broader evidence-gathering exercises for commissioning and is frequently overlooked. Attention to this kind of evidence is most often dependent on the interests and expertise of individual actors and consequently remains a distinct exercise, with resulting knowledge not being widely shared.

National policy directives, although rarely specific to ethnic inequality, can be influential in prompting attention to research and other evidence on ethnic diversity and inequality, and can provide helpful levers for actors who wish to address ethnic health inequalities. At all of our sites, for example, the external audit linked to infant mortality reviews prompted requests for data on birth outcomes and ethnicity and a focus on initiatives aimed at reducing ethnic health inequalities. Although there has been investment by the DH in initiatives such as Race for Health and Pacesetters, which aimed to improve the commissioning of health services to address the needs of minority ethnic populations, there has to date been poor articulation of the role that commissioners should play in effectively bringing evidence to bear on such commissioning decisions. Furthermore, this kind of national leadership is not consistent or strategic, suggesting that the interests and expertise of individual policy actors are key factors at national as well as local levels. Furthermore, a heavy reliance on synthesised evidence from national sources, such as the DH or NICE, is problematic when this contains no details on ethnicity.

Evidence linked to service failures, such as poor take-up of provision, low levels of satisfaction or poor health outcomes for particular ethnic populations, is less often a prompt to action for commissioners. Our findings demonstrate that routine performance monitoring systems within services do not often include a focus on ethnic equality, or indeed any dimension of equality, and commissioners themselves rarely request that such data be collected. When such data are available they can, however, play a similar role to national evidence overviews and provide a platform from which individual actors can seek to influence commissioning decisions.

We found that the competency of those involved in commissioning to (1) identify and access, (2) critically appraise and synthesise and (3) adapt and apply evidence relating to ethnic diversity and inequality was very variable and, as with commissioning in general, we identified some significant skills gaps. In some cases creative approaches to fill evidence gaps are found, such as combining national quantitative data with local qualitative feedback to highlight unmet need; however, such approaches need to be more widely shared within commissioning organisations.

Hunter70 argues that, in exploring the role of those in policy-making positions, we must ‘consider these individuals as emotional as well as relational actors’ (p. 150). For example, professional anxiety and uncertainty about how to achieve cultural competence is disempowering to professionals and detrimental to care. 49 Our findings highlight the absence of action within strategic and operational commissioning processes and structures that would dispel such uncertainty. Furthermore, there is little or no challenge to conceptual models of commissioning that perceive a focus on particular ethnic groups as ‘privileging’ these populations or unnecessarily specifying communities that are felt to be already included within a generic framework for ‘the whole population’. As our findings highlight, such approaches serve to reinforce social exclusion and maintain or exacerbate health inequalities experienced by minority ethnic groups. There is consequently a need for tools that improve understanding of ethnicity and its relationship to health, which often remains unsophisticated and problematic.

We found that the limited range and quality of the available evidence on ethnic diversity and inequality is often a barrier to actors who do wish to engage with the field of ethnic health inequalities. At the same time, gaps in the data from service providers are sometimes imagined rather than real and there is the potential for existing data on ethnicity, which may exist but not be requested, to be analysed in ways that could helpfully inform commissioning decisions.

Respondents often expressed a desire for evidence about how to reduce ethnic health inequalities rather than more research about what these were, and our findings confirm that intervention studies is an area on which research on ethnicity and health needs to focus, as highlighted elsewhere. 44 High-quality evaluations exploring effectiveness and costs are important for transformational commissioning in the area of ethnic health inequalities. Although evidence from local sources on ‘what works’ may be valued for its contextual relevance, it is vulnerable to being contested in terms of its credibility, particularly if put forward by third-sector organisations who may be seen as unrepresentative of those whom they purport to advocate for, or as having vested interests in, promoting work in this area.

Generic organisational constraints

We found patchy and inconsistent application of evidence at all stages of the commissioning cycle alongside isolated examples of comprehensive and effective evidence mobilisation and use. Public health staff are important actors in relation to needs assessment activity; however, the fragmented nature of commissioning work may mean that their skills are not routinely utilised. In addition, the skills needed for other aspects of evidence mobilisation and use, such as the identification and synthesis of data from diverse sources, may not be well represented across a commissioning organisation and these aspects are therefore often neglected. The routine use of evidence in commissioning appears to be constrained by an absence of staff with specific evidence mobilisation roles, and commissioning models, structures and processes do not currently support the routine generation and use of evidence as an indispensable aspect of decision-making. The general sense from our data is therefore of idiosyncratic and unstable practices linked to an absence of organisational expectations or support for knowledge mobilisation.

Although a ‘transformation agenda’ was articulated by strategic managers at all three of our sites, this appeared to be focused on a narrow range of service areas; in other areas the absence of this focus – through incentives or penalties for such work – made narrowly transactional approaches to commissioning more likely. In general, low priority appears to be afforded to the use of evidence as a commissioning activity, indicated by constraints linked to organisational culture and practice: lack of time, resources and skills to carry out such activity; silo working; and some commissioners having poor knowledge of the service area for which they have responsibility. Our findings suggest that, in the current climate, access to and use of relevant evidence to support a transformation agenda, such as evaluations of service redesigns, is secondary to other internal processes that focus on cost saving within short timescales.

The context for use of evidence on ethnic diversity and inequality

We found efforts to establish teams that encompassed a range of perspectives and skills, such as integrated commissioning teams and planning and commissioning groups. However, valued attributes for such teams rarely ensure the presence of individuals with an understanding of evidence relating to minority ethnic health needs. When good practice on evidence use exists this does not tend to have content relevant to ethnic health needs. Although some of our respondents recognised their own limited expertise and indicated willingness to develop their capacity in relation to these issues, there was little encouragement or incentive from key drivers to do so and no mechanisms for accountability that would support their aspirations, particularly in the context of tight deadlines and a pressured environment. Managerial priorities largely deter consideration of evidence relating to ethnic diversity and inequality within commissioning teams by a practice of omission; there is no reward or sanction for attention to such evidence and no challenge to those who perceive that this consideration complicates matters further than necessary.

Our findings highlight various missed opportunities to consider such evidence within the available resources and infrastructure, such as the quality and transformation agenda, in which there is the potential for considerable overlap with addressing unmet need in minority ethnic communities. Our findings confirm that neglect of the dimension of ethnicity within the national health inequalities agenda appears to have had a major adverse impact on meeting unmet need within minority ethnic populations, as argued elsewhere. 105,106 There appears to be a clear interplay between how these agenda are conceptualised at national, regional and organisational levels in terms of policy priorities. Although some key actors recognise the potential to align these more, the general picture is one of omission, ambivalence and marginalisation at national level. This is unsurprisingly reflected at organisational level, resulting in low demand for this type of evidence. Interest in and use of evidence relating to ethnic health inequalities is unlikely when such issues are not raised and questions that need answers are not asked.

Expertise in and insight into ethnic health inequalities is thus not considered a general concern and our findings show that this responsibility is often concentrated within staff in E&D roles, on whom there may be heavy reliance not only to provide understanding of such inequalities but also to ensure that commissioners meet legal obligations. Third-sector organisations, which are often utilised to engage with groups perceived as ‘hard to reach’ (or ‘easy to ignore’), are not necessarily recognised as holding expertise and at times their insight may be questioned. BME staff members may be assumed to have such expertise and some report resisting responsibility for ethnic health inequalities when this is neglected in terms of commissioning priorities. The view that aligning oneself with a marginalised issue is likely to impact on one’s position within the organisation in general is perhaps understandable; however, it also contributes to the continued marginalisation of evidence in this area.

Given the significance of individual interest and expertise in generating attention to evidence on ethnic health inequalities outlined earlier, who is involved in commissioning is of crucial importance. Our findings indicate constraints on the ability and capacity of those most likely to promote such evidence to be involved in commissioning processes and structures. Staff in E&D posts may be accorded a narrow focus in terms of their remit and are not embedded in the structures and processes that routinely contribute to commissioning decisions. Their influence on commissioning consequently appears to be ad hoc and dependent on pre-existing relationships. The poor representation of people from minority ethnic communities at all stages of the commissioning cycle is also a key factor influencing the low priority and fragmented nature of attention afforded to evidence on ethnic diversity and inequality. Although we found some positive examples of user input, in which extended and meaningful engagement of minority ethnic patient representatives had occurred, this was neither consistent nor normal practice.

Our findings also highlight wide variation in the extent to which third-sector providers, where expertise in engaging with minority ethnic communities is most likely to be found,107 are regularly engaged in commissioning teams. Examples of service users or organisations that represent their interests prompting managers to seek out and use evidence were rare; individuals or groups working within minority communities did not often have the capacity or resources to effectively engage with evidence sources or commissioning structures in ways that could significantly influence decision-making. Most significantly, membership of commissioning groups was not representative of minority ethnic populations, limiting the extent to which members’ individual expertise and knowledge of evidence on ethnic health inequalities could inform work undertaken and making performance management in this area unlikely. Thus, more often than not, commissioning structures appear to reflect and maintain the more general social exclusion of minority ethnic communities, reinforcing the status quo rather than modelling the social change needed to reduce exclusion and inequalities. 108

Such contexts, in which key actors may have little knowledge or understanding of the need to address ethnic inequalities, can help explain why higher standards of evidence are often required for small-scale service developments to meet the needs of minority ethnic communities than for multimillion pound contracts to large providers. Those who argue for such development may be required to produce robust evidence that demonstrates unmet need and a business case showing cost-effectiveness, which is often impossible given the gaps in existing evidence on ethnic diversity and inequality. An evidence-based culture can thus not only undermine progress towards reducing ethnic health inequalities but also mask the underlying factors that cause commissioners to be risk averse in this area of activity.

Individual and team-level support

At the level of individuals involved in commissioning our findings suggest that knowledge, awareness, skills and experience, the ‘mental models’ of commissioning used and personal background are all likely to facilitate or hinder the mobilisation and utilisation of evidence on ethnic health inequalities. A strong theme in our data was the high dependence on individual interest, commitment and capacity to engage with this agenda. Although this may be linked to organisational context and team dynamics it also requires attention in its own right, given that many individuals were championing the issue of ethnic health inequalities despite low levels of organisational interest and others felt poorly equipped to engage with this agenda.

Our findings suggest that increased awareness of the relevance and importance of ethnic health inequalities would improve conceptual understandings of both the commissioning role and the relationship between ethnicity and health. This kind of support could help increase the demand for evidence on ethnic diversity and inequality. There is also a need to increase awareness of the different sources from which existing evidence may be available. Support for skills in synthesising, critically appraising, packaging and presenting evidence is also necessary as these skills appear crucial to mobilising evidence use in terms of commissioning action that could reduce ethnic inequalities in health-care access, satisfaction and outcomes.

The need to increase and enhance the routes through which evidence relating to ethnic diversity and inequality currently finds its way into the commissioning process is also suggested by our findings. These are currently ad hoc and precarious and receive little attention. Support to develop structures that facilitate regular inputs from important actors, such as practitioners, third-sector organisations, user and carer groups and academics, is likely to increase access to the important sources of insight and ideas for innovation that they can bring. Strategies for developing long-term relationships are needed along with ways of engaging that empower these actors as critical friends or external agitators so that they can confidently bring evidence to the commissioning arena.

Current barriers to mobilising and using evidence on ethnic diversity and inequality exist at both individual and organisational levels. Our findings highlight a lack of leadership in terms of a low demand for such evidence and failure to recognise its relevance. This is particularly significant in key, well-resourced areas of commissioning activity. More clarity about how commissioners could be expected to link ethnic health inequalities with mainstream activity is needed, along with good practice examples demonstrating what service models should look like in relation to minority ethnic needs and how these can be achieved. Support for organisational activity must crucially come through national drivers, which dominate the commissioning agenda and which are not often defined in relation to ethnicity.

Once demand for evidence is generated, support is also required to deal with problems that exist with the evidence base that is currently available and expectations about what this should deliver. Creative approaches to dealing with evidence gaps and incomplete data need to be disseminated widely and should draw on mainstream commissioning practices, which may sometimes face similar problems. For example, an incremental approach to data gathering using audit procedures, observed at one of our case study sites, appears to be a promising approach for dealing with the current gaps in ethnic data monitoring. Strategies for overcoming and dealing with a lack of evidence on effective interventions and a lack of cost-effectiveness studies are also required as well as guidance on how to synthesise different sources of evidence on ethnic diversity and inequality, and how to translate findings from one context to another. For example, our findings suggest that combining evidence from national data sets with very local qualitative evidence can be helpful in addressing the need for credibility alongside a preference for data that take account of local contexts.

Support at organisational and national level

Organisational legitimacy for work on ethnic diversity and inequality and an enabling environment appear to be of fundamental importance to the mobilisation and use of evidence in this area. The routine, critical use of research evidence in commissioning for multiethnic populations is currently hampered by national drivers that reflect poor understanding and consequent ambivalence towards ethnic health inequalities. Our findings show that strategies for linking mainstream activity with work to reduce ethnic health inequalities do exist, but require more dissemination and further development. Wider societal discourses that question the entitlements of minority ethnic people or seek to silence discussions of ‘race’ and racism can also prevent attention being given to the significant body of evidence on ethnic health inequalities. Effective responses to these challenges need to be formulated and disseminated to support individuals faced with such barriers, thereby reducing their impact and supporting alternative discourses that focus on equity and social justice.

An enabling environment is characterised by senior commitment to reducing ethnic health inequalities, reflected in strategic frameworks, service specifications and monitoring processes that specifically address this issue. Our findings suggest that the Equality Delivery System may have the potential to provide the strategic framework within which such legitimacy can be expressed if it is explicitly adopted and promoted by senior executives within commissioning organisations.

The capacity to draw effectively on a range of evidence on ethnic diversity and inequality appears most likely to develop when organisations resource senior-level appointments dedicated to providing a continuous in-depth focus on this area of activity. Our findings also suggest that capacity to understand and generate evidence on ethnic diversity and inequality is more likely within the context of a diverse workforce that represents the populations it serves. We found that access to a broad spectrum of evidence is made possible through collaboration with wide, cross-disciplinary groups of relevant stakeholders, including those who may challenge existing practices. A constructive and open approach and investment in long-term engagement with such groups is most often found to support the co-production of knowledge that leads to innovative approaches and adaptations of existing levers.

Pooling capacity through networks and regular meetings of E&D staff within and between organisations enables information sharing, for example about successful interventions. These structures can also support cross-sector work and avoid duplicate activity generating evidence from the same sources. Informal networks and relationships also appear to be important in terms of improving access to different sources of information, and developing ‘allies’ that can increase support from senior decision-makers.

We found that the ability and confidence to package evidence in ways that are credible and meaningful is important in terms of influencing those involved in commissioning to adopt an ethnicity focus. This kind of influential use of evidence is likely to feed back into, and reinforce, the organisational legitimacy of this agenda, potentially leading to further resource allocation.

The need for easy access to a diverse range of qualitative and quantitative, nationally and locally produced evidence and synthesis briefings that increase understanding of, and commitment to, reducing ethnic health inequalities is also suggested by our findings. These would need to be presented in ways that inform and influence individuals, commissioning groups and policy-makers at local and national levels. Support to understand what kinds of data on ethnicity would be meaningful in particular contexts is also necessary, given the complex underlying causes of ethnic health inequalities and the need to target resources in areas that are likely to make most difference.

Increasing demand for evidence on ethnic diversity and inequality

• Encourage an understanding of commissioning that focuses on meeting heath needs rather than transactional approaches and that embeds a requirement to address health inequalities and population diversity.

• Show political will and commitment by establishing senior leadership roles and incentives for commissioners to mobilise evidence on these issues within all areas of commissioning activity.

• Ensure that attention to ethnic diversity and inequality is addressed in well-resourced areas of commissioning activity, such as that stimulated by national initiatives and drivers.

• Link to national-level support that provides guidance and promotes consistency and good practice amongst commissioners in diverse geographical and service areas.

• Provide standards and models for service specifications that include targets and measures relating to ethnic diversity and inequality.

Increasing access to varied sources of relevant evidence

• Create a local infrastructure that supports information sharing, pooling of expertise and cross-sector work for those working in this area of activity.

• Promote the active contribution of knowledge from a wide range of stakeholders, including E&D staff, minority ethnic service users/carers and organisations that represent their interests, and academics with relevant expertise.

• Encourage an incremental approach to filling data and evidence gaps, using audit processes, service specifications and research as tools to support this development.

• Seek out evidence that would support a transformational approach to service provision in areas in which current configurations are unlikely to reduce ethnic health inequalities.

• Develop, pilot and evaluate interventions that produce evidence on what works to reduce ethnic health inequalities where this is not currently available.

• Provide incentives and resources to disseminate good practice locally and nationally and use a wide range of networks and dissemination routes to achieve this.

Enhancing confidence and competence to use evidence critically and systematically

• Expect E&D work to be evidence based and to provide opportunities to upskill staff specialising in this area and to link them more effectively to evidence experts.

• Expect all commissioning staff to understand the importance of meeting minority ethnic needs and provide opportunities for staff to gain the necessary skills and experience to work confidently and competently in this area.

• Establish routes to wider commissioning activity through which commissioners can seek out creative approaches to problems with current evidence on ethnicity.

• Work to overcome fragmented, isolated activity by bringing together different pieces of work in this area under a strategic framework such as the Equality Delivery System, and showcase and reward such work.

A number of the areas for support outlined above have been addressed through the development of tools for use by individual managers, teams and organisations to enhance performance in this area (see http://research.shu.ac.uk/eeic/index.html). Further research will aim to explore the use of the tools in practice to support further their refinement.

Aims and objectives

Goal: To support the commissioning of health services that better meet the needs of black and minority ethnic patients and thereby help reduce ethnic inequalities in healthcare experiences and health outcomes.

Aim: To enhance the critical use of research evidence alongside other forms of knowledge by managers within the PCT commissioning cycle.

Objectives:

Theoretical:

• To develop a theoretical model of knowledge utilisation that explicates the emotional, ideological and political dimensions through the example of ethnic diversity and inequality.

• To contribute to the theoretical literature that addresses mechanisms for enhancing the critical use of research evidence by managers in complex decision-making environments.

• To contribute to the theoretical literature that addresses mechanisms for enhancing the cultural competence of healthcare services by integrating an understanding of the role of knowledge(s) mobilisation.

Empirical:

• To describe, across a range of commissioning contexts, how managers seek out, appraise and apply research evidence relating to ethnic diversity and inequality alongside other forms of knowledge.

• To identify factors (at evidence, individual and contextual levels and their interfaces) that support or inhibit the critical and effective use of research evidence within the commissioning cycle and thereby identify promising routes of intervention.

Operational:

• To develop practical diagnostic, evaluative and change management tools for use by individual managers, teams and organisations to (i) assess and promote critical reflection on current competencies and practice with respect to utilisation of evidence on ethnic diversity and inequality, (ii) identify actions to strengthen competencies and good practice and (iii) support specific elements of the knowledge utilisation process.

• To educate researchers and research funders regarding the current limitations of the evidence base and how they might generate research products that are more appropriate and accessible for managers charged with the task of commissioning services for multiethnic populations.

• To strengthen links between university researchers and managers and contribute to the development of a shared commitment to enhancing research evidence utilisation for enhanced organisational performance.

Background

While the volume of enquiry into the mobilisation and utilisation of research evidence within the health sector is growing rapidly, there remain important gaps in our understanding about which strategies work to encourage better use of research evidence and how and why specific approaches might work. In particular, our understanding of knowledge utilisation processes within the policy context is far weaker than for the clinical practice environment (Pettigrew et al, 2004). The current project responds to this gap in our understanding by exploring the PCT commissioning cycle – an increasingly powerful determinant of the NHS services on offer and the care that patients receive - and by explicitly focusing on an area that has so far been overlooked, namely the mobilisation and utilisation of evidence relating to ethnic inequalities in health. While no prior studies have engaged with our specific area of focus, we identify three bodies of work that can be drawn upon and integrated to identify fruitful new avenues of investigation.

First, a growing body of studies explores knowledge mobilisation and utilisation within the health policy-making arena, and some take an explicit focus on health inequalities. Much of this work draws on broader theoretical perspectives that view policy making as a process of collective interaction between diverse stake-holders in which both the identification of, and responses to, problems, are viewed as socially situated and constructed (Yanow 1996; Colebatch, 2005; Hanney et al. 2003). These contributions highlight the distinctive nature of evidence utilisation in policy formation (at both strategic and service-design levels) when compared to the clinical practice context (Black 2001; Pettigrew et al., 2004). Kelly and Swann (2004) note the way in which evidence syntheses within public health can only offer ‘scientifically plausible frameworks for action’ (p270) and not prescriptions for specific intervention, since decision-making requires judgements based on knowledge of local context including prevailing practices, organisational structures, commitment and engagement of key actors. Similarly, Elliot and Popay’s (2000) investigation of evidence use by NHS managers revealed that research was felt to offer clarity and to contribute to decision-making but rarely to provide simple, clear-cut answers. Other work confirms that healthcare policy-makers work with a ‘mixed economy’ of evidence, piecing together information from diverse sources in their decision-making (Pettigrew et al., 2004; Whitehead et al., 2004).

Blackman et al. (2006) look particularly at policy-making related to health inequalities and identify this area as a ‘wicked problem’ that cuts across traditional organisational boundaries and whose complexity limits the scope of evidence-based action. ‘Wicked problems’ tend to carry with them greater scope for debate around what should be done and how it should be achieved and more room for disagreement on what counts as robust and relevant evidence. They suggest that policy-making in relation to ‘wicked problems’ tends to be less a technical exercise and more a process of dialogue and argument with power relationships clearly in evidence. Exworthy et al., (2006) highlight similar factors that may complicate the knowledge-into-action process relating to the health inequalities agenda, including the multiplicity of agencies and the diffuse nature of responsibility. While this past research exploring the utilisation of evidence within the health inequalities context is an important backdrop to the present study, there is a need for enquiry that specifically focuses on ethnic diversity and inequality. Mir and Tovey’s (2002) study begins to explore these issues and shows that whether managers act upon research and other knowledge is shaped by resources, organisational culture and particularly the absence of substantial disincentives. There is a need for further systematic study of the factors that hamper or facilitate the effective utilisation of research evidence relating to ethnic diversity and inequality, particularly because of the significant additional issues that arise in terms of the generation and application of a research evidence base in this area and also because of the embedded nature of racial discrimination within UK society.

Turning first to the consider the research evidence base, work that engages with the ethics and science of researching ethnicity and health is pertinent but has yet to be integrated with research that explores the role of the characteristics of research evidence within utilisation processes. As the volume of research on ethnicity and health expands, so too do concerns regarding quality, its potential role in stereotyping and stigmatising ethnic minorities, and its limited benefit to minority ethnic populations (Gunaratnam, 2007). Critically appraising and applying research evidence on ethnicity and health presents significant challenges and demands particular competencies (Salway and Ellison, 2009). Issues include the need to: interrogate conceptualisations of ethnicity that erroneously present ethnic ‘groups’ as stable, discrete entities and/or fail to address its multifaceted nature; question whether research adequately addresses the concerns of minority ethnic people; recognise the limited analytical potential offered by crude administrative ethnic categorisation; and carefully consider how evidence can best be synthesised across contexts when concepts and categorisations vary widely (Bradby, 2003; Gerrish, 2000; Morning, 2008). These issues are likely to impact importantly on how managers use research evidence relating to ethnic diversity and inequality, though to-date this has not been explored.

Related work in the broad area of health inequalities highlights a number of factors related to the characteristics of research evidence and research products that have relevance to the focus of the present study. Exworthy et al., (2006) suggest that the multifactorial nature of inequalities, the paucity of evidence of effective interventions and the need for upstream and long-term investments all complicate the knowledge-into-action cycle in health inequalities policy. Pettigrew et al. (2004) found that policy-makers charged with the health inequalities agenda commonly perceive the lack of locally relevant evidence and evidence on the distributional effects of interventions to be problematic. More generally, Greenahalgh et al. ’s (2004) major review of innovation diffusion in healthcare organisations identifies a number of key attributes of successful innovation that are rarely applicable to the evidence base on ethnic diversity and inequality including: evidence of clear benefits and cost-effectiveness; low complexity; ease of adaptation and low risk or uncertainty. Indeed, utilisation of the research evidence relating to ethnic diversity and inequality is likely to be compromised by: the predominance of grey literature; the lack of evaluative studies; the lack of studies that consider the distributional effects of interventions by ethnicity; and the lack of consideration of ethnicity within influential evidence syntheses (e.g. Cochrane reviews, NICE guidelance) (Yamanda and Brekke, 2008).

Notwithstanding weaknesses in the evidence base that need to be filled, there is nevertheless a substantial body of evidence that highlights the scale and nature of the health disadvantage suffered by black and minority ethnic groups, as well as evidence that identifies generic ways in which health services could be modified to better meet the needs of minority ethnic patients (such as the provision of adequate interpretation facilities and enhanced cultural competence among healthcare providers, (Kai et al., 2007; Betancourt et al., 2005)). Furthermore, in some service/disease areas the quality of the research evidence base could lend itself to more specific, instrumental use by commissioners in pursuit of improved outcomes for minority ethnic groups such as evidence-based diabetes interventions (Bellary et al 2008). However, while many studies have identified factors that shape whether such research evidence impacts upon policy or practice (Hanney et al., 2003; Susawad, 2007), none have specifically engaged with the issue of ethnic diversity and inequality. More needs to be understood regarding the factors that support or inhibit the use of evidence in this context including: how evidence is presented and conveyed to decision-makers; what is regarded as evidence or knowledge; how the quality and relevance of knowledge is assessed; when evidence is regarded as necessary; how easily evidence can be accessed, appraised, synthesised and integrated with other knowledge so that it can be adapted to the local context; and how decision-making is achieved in the absence of adequate research evidence.

Finally, our study is informed by, and seeks to further develop, the body of work that explores factors involved in achieving cultural competence within healthcare organisations. Attempts to translate knowledge about ‘cultural competence’ into improved healthcare experiences and outcomes for black and minority ethnic patients have most often adopted either training/education or evidence-based practice approaches. To-date, there has been no investigation of how research evidence informs policy-making or the commissioning of services for multiethnic populations. Nevertheless, past studies of training/education or evidence-based practice approaches do offer some useful insights.

Several studies highlight the way in which education and training programmes designed to address gaps in professional knowledge require wider, systems-based approaches to achieve desired shifts in practice. Kripalani (2006) notes the importance of clear support from senior staff in terms of signifying priority and modelling desired behaviour, Yamada and Brekke (2008) identify the need for attention to organisational factors influencing practice, and Shapiro et al. (2006) suggest that practice-based learning and models of good practice are needed alongside training courses. These findings point to the embedded nature of practitioner assumptions and behaviours and the need to challenge ‘tacit knowledge’ through new learning that is context-specific, has a link to action and is informed by experience (Russell et al., 2004).

An evidence based practice (EBP) approach to developing culturally competent services has combined best available research evidence with clinical expertise in the context of individual client characteristics. This approach has drawn on research highlighting the significance of systems in the development of culturally relevant interventions and the importance of practitioner self-awareness (Yamada and Brekke, 2008). EBP efforts are hampered, however, by a lack of evidence about specific ways in which practice guidelines should be modified to improve health outcomes for minority ethnic populations (Chen et al., 2008; Yamada and Brekke 2008) and omission of these populations from studies of evidence-based treatments (Whaley and Davis, 2007). The lack of evidence on the efficacy and cost effectiveness of cultural competence interventions may result in these being seen as an extra burden, particularly in the context of staff shortages and financial restrictions (Engebretson et al., 2008).

In addition to the above work, there is a large body of research that explores ‘cultural competence’ within healthcare from an organisational development perspective without engaging specifically in an exploration of the mobilisation and utilisation of research evidence. Analyses that situate the formulation of healthcare policy and practice within the wider sociocultural context of contemporary Britain are helpful. Despite sustained attention, UK policy relating to ethnic diversity lacks coherence and suggests at best ambivalence towards minority ethnic groups and dissensus regarding the form that multicultural Britain should take (Ahmad 1993; Culley, 2006). Two significant wings of policy and legislation – relating to immigration control and citizenship on the one hand, and to racial equality on the other – conflict (Hepple, 1992). Atkin and Chattoo (2007) argue that strategies for addressing disadvantage in healthcare provision are undermined as providers and managers struggle to reconcile these conflicting messages regarding minority ethnic populations; their needs and entitlements. It is increasingly argued that progress towards more culturally competent health services requires practitioners and organisations to: examine value bases; expose stereotypes, prejudices and ethnocentrism; challenge power relationships and oppressive practices; and work in true partnership (Papadopolous et al., 2004). It is noteworthy, however, that while such models often emphasise the importance of community consultation and local intelligence data, they are commonly silent on the role of research evidence (Dreaschlin, 2007). Similarly, recent policy documents and initiatives aimed at supporting commissioners and managers to address ethnic diversity and inequality pay little attention to how research evidence might be mobilised and utilised in this endeavour (Race for Health, n.d.; Race for Health, 2009). This is particularly surprising given the significant recent investments and initiatives aimed at fostering an evidence based approach to tackling ethnic inequalities, including the Ethnicity & Health specialist library of NHS Evidence. The present study seeks to address these important gaps.

While research to-date has helped to describe the complexity of the processes involved in, and the very wide range of factors that can act as barriers to, the knowledge utilisation process (Greenhalgh et al., 2004; Mitton et al., 2007; Susawad, 2007), as yet little has been done to identify effective routes to shaping or enhancing the process in real-life policy-making contexts. There is a need to move towards identifying effective areas for intervention – so-called ‘weak points’ – where intervention can effectively shift embedded values, beliefs, structures and practices that serve to undermine the contribution of research evidence. The present study aims to contribute to this general need and to generate specific understanding in an important area that has not to-date been the focus of enquiry.

Need

The study’s focus on enhancing critical use of evidence in the commissioning process aims to enhance the quality, acceptability and effectiveness of services for minority ethnic communities, which comprise 13% of the population of England (in terms of those identifying as other than ‘White British’ in the 2001 Census). Mortality and morbidity patterns are complex, however substantial evidence indicates that minority ethnic groups suffer significant disadvantage across a range of indicators (Nazroo, 1997; Natarajan, 2004; Gill et al., 2007) as well as lower satisfaction with services (e.g. DH/HCC, 2008). The study will support managers to utilise evidence to improve commissioning and delivery of healthcare that effectively serves the needs of minority ethnic people, an area in which progress has been limited to-date (Culley and Dyson, 2001). Better use of evidence will help to overcome persistent problems relating to ineffective and insensitive patient–provider interactions, inappropriate constellation and design of services, inequitable allocation of resources and ethnocentric and oppressive cultures of care, that have been documented across a variety of service settings (e.g. Singh and Newburn 2000; Bhui et al., 2007). The research products will have pertinence to the increasing ‘ethnic diversity’ of the UK population considering both persistent disadvantage among established minority communities alongside the differing health needs of new migrant populations. The study therefore responds to the Commission for Equality and Human Rights’ (previously the CRE) formal investigation into the Department of Health, and Nigel Crisp’s 10-point action plan response, which highlight the need for significant improvement in this area.

Past policy intentions to tackle ethnic health inequalities have been undermined by competing priorities and diffuse locations of responsibility. However, recent policy developments and NHS reforms signal the alignment of efficiency and equity principles (including the NHS Constitution, DH, 2009; High Quality Care for All, DH, 2004; and World Class Commissioning, DH, 2007) and create new opportunities for evidence-driven commissioning by primary care trusts (PCTs) (King’s Fund, 2007). Key competencies for today’s PCT commissioners place knowledge management centre stage and include: critically mobilising and utilising research and best practice evidence; effectively garnering local intelligence and promoting engagement to assess needs; turning information into knowledge and action for service reconfiguration that improves access, quality and outcomes (DH/Commissioning, 2007). Commissioners are to be transformatory, rather than transactional, encouraging innovation and ambition to serve those in greatest need. The role of public health teams in the commissioning cycle, via both profiling local populations and synthesising wider research evidence, is gaining importance (PHCN, 2009). At the same time, Practice Based Commissioning (PBC) is increasingly promoted as a way to ensure that practitioner experience and insight effectively inform the design and delivery of services. Practice Based Commissioning consortia are intended to articulate population needs and identify innovative solutions to delivering better care and increased patient choice more efficiently. While World Class Commissioning and PBC present important opportunities, it is clear that they also demand significant development in competencies and infrastructure, particularly in relation to the mobilisation and utilisation of evidence. For instance, early investigation by the King’s Fund (2007a) suggests that a lack of timely and high quality information currently undermines effective PBC. The current project responds to the needs of this emergent commissioning environment by seeking to enhance PCT managers’ critical use of evidence in their task of commissioning services for multiethnic populations.

Enhancing the utilisation of evidence is particularly pertinent to the task of tackling ethnic inequalities in health. As well as better ethnic monitoring at local level, there is a need for better understanding of ethnic inequalities in health – their nature, causes and potential solutions – among those responsible for commissioning services (Aspinall and Anionwu, 2002; King’s Fund 2007b; Yorkshire & Humber SHA, 2009). Furthermore, while there has been significant investment by DH in initiatives aimed at improving the commissioning of health services that address the needs of minority ethnic populations (for instance Race for Health and Pacesetters), there has to-date been poor articulation of the role that research evidence should play or how commissioners should be supported to effectively bring research evidence to bear on such commissioning decisions. This project extends and links several strands of ongoing collaborative work focused on knowledge translation, intelligent commissioning and ethnic diversity and inequality between university researchers and PCTs. The research focus has been jointly identified and responds to expressed needs among NHS managers. Recent events indicate a high level of interest in this area nationwide (King’s Fund, 2007b; Yorkshire & Humber SHA, 2009), so that the project will have relevance to current and future priorities of PCT managers both regionally and nationally. The project will generate new empirical and theoretical understanding of the factors that shape effective utilisation of evidence relating to ethnic diversity and inequality and identify promising routes of intervention to enhance such use. The project will then use this new knowledge to design specific tools to enhance performance in this area, for use by individual managers, teams and organisations. Managers in Public Health, Workforce and Corporate Development as well as Commissioning Directorates are particularly likely to benefit from these outputs. The study addresses the SDO’s core aims through its focus on improving practice in the organisation and delivery of health care for minority ethnic communities in the UK and contributes an added dimension to theoretical knowledge to the knowledge utilisation literature. By generating new knowledge about the way that managers perceive and utilise evidence on ethic diversity and inequality within the PCT commissioning cycle, and developing tools which help to apply this knowledge, the project represents good value for money. Further, by linking to the NIHR CLAHRC programme, the project’s tools will be taken forward into pilots to test their impact on commissioning practice and outcomes.

Methods

Research questions

We identify below the three broad research questions that guide the empirical components of the study. Each broad research question is followed a set of more detailed questions that illustrate the range of issues that are likely to be relevant and that indicate our intention to explore five inter-related ‘levels’ – evidence, individual managers, commissioning team, organisational setting and wider context – that make up the knowledge mobilisation and utilisation process.

RQ1: How does a focus on ethnic diversity and inequality shape the knowledge mobilisation and utilisation process within the health services commissioning context?

• What characteristics of research evidence relating to ethnic diversity and inequality influence how it is received by managers? (e.g. source; method, (un)certainty; relevance; concepts/theory);

• What mental models of ‘how research evidence should be used’ are managers working with?

• To what extent is the accessing and application of information relating to ethnic diversity and inequality part-and-parcel of broader evidence gathering exercises for commissioning, or rather a distinct exercise?

• What factors prompt managers to seek out research (and other types of evidence) relating to ethnic diversity and inequality? (policy directives, new priorities, external audit, stakeholder inputs, signs of service failure etc.)

RQ2: How does organisational context shape the mobilisation and utilisation of knowledge relating to ethnic diversity and inequality?

• How often, and at what stages, do managers apply research evidence relating to ethnic diversity and inequality in their commissioning tasks?

• How are commissioning teams constituted and organised? How does this impact upon evidence use?

• Who is seen as holding expertise and insight in relation to ethnic diversity and inequality? Why?

• To what extent do PCT commissioning organisations have explicit models, structures, processes and objectives that support the mobilisation and utilisation of evidence? Do these consider ethnic diversity?

• In what ways does managerial behaviour support and encourage, or deter, the explicit consideration of research evidence relating to ethnic diversity and inequality within commissioning teams?

• In what ways do the available infrastructure and resources support and encourage, or deter, the explicit consideration of evidence relating to ethnic diversity and inequality within commissioning teams?

• How do national, regional and organisational policy priorities inter-relate to shape the mobilisation and utilisation of evidence in this area?

RQ3: How can individual, team and organisational competencies be effectively enhanced to support critical use of research evidence for the commissioning of services that better meet the needs of a multiethnic population?

• How competent are managers to (i) identify and access, (ii) critically appraise and synthesise; (iii) adapt and apply, evidence relating to ethnic diversity and inequality?

• What expectations do managers have of, and what problems do they encounter with, the evidence base?

• What individual level factors facilitate or hinder the mobilisation and utilisation of research evidence in this area (knowledge/awareness; skills and experience; ‘mental maps’; autonomy; authority; personal biography)?

• What areas of capacity development would likely improve the individual and team-level competencies required for the mobilisation and utilisation of research evidence relating to ethnic diversity and inequality?

• How does research (and other) evidence relating to ethnic diversity and inequality currently find its way into the commissioning process; via which actors and which routes? How can these be supported?

• Who are the key actors and what are the key organisational settings and processes that present barriers against enhanced mobilisation and utilisation of evidence?

• What factors in the wider societal and broader NHS context must be buffered against, or can be drawn upon, to support the routine, critical use of research evidence in commissioning for multiethnic populations?

• What characteristics of the form, content and delivery of interventions in support of enhanced mobilisation and utilisation of research evidence are likely to increase relevance and utility?

Research phases, methods and links to research questions

Preparatory work: Prior to the official start of the project the following tasks will be initiated if funding is confirmed from SDO: applications for ethics and governance clearance, recruitment of the full-time researcher and Advisory and User Guidance Group establishment.

Phase 1 (Oct–Dec 2010): Preparatory work; ethics and governance approvals; team building; literature up-dating; researcher induction. Literature reviewing and updating will focus particularly on new evidence relating to the form and content of interventions that have been shown to be effective at enhancing evidence utilisation in policy-making settings and will thereby contribute towards answering RQ3 above. Meeting of the Project Advisory Group and the User Guidance Group. Towards the end of this phase an internal briefing paper will be written to clearly articulate the conceptual framework and methodological approach guiding the project.

Phase 2 (Jan–Jun 2011): Expert Interviews (N = 30–40) The purpose of Phase 2 is threefold (i) to gain, from a broad range of perspectives, insights into the key characteristics (relating particularly to the research evidence base, the PCT commissioning context, and the wider socio-political setting) that facilitate or hamper progress towards evidence utilisation in pursuit of reduced ethnic health inequalities, and thereby contribute to answering RQs 1 and 3 above; (ii) to document elements of good practice that have been developed during the PCT commissioning period that are valuable to preserve and promote as we move forward into new commissioning structures; and (iii) to inform the shape and focus of the Phase 3 case studies. Expert, in-depth interviews are well-suited to gaining insights into the structure and functioning of particular, complex environments (Berndtson et al. , 2007) and recent studies have confirmed the usefulness of gaining expert opinion regarding the research–practice interface in relation to health inequalities (Lavis et al., 2008). An initial sample of 10–15 respondents will be identified through professional networks and contacts including those of our Project Advisory Group and the CLAHRC initiative. Subsequently, a modified snowball approach will be used in which respondents will be asked to recommend individuals who can offer particular perspectives. The main inclusion criteria will be that respondents are able to provide a detailed perspective on the evidence–practice interface within healthcare policy making. Different respondents will have differing expertise, but we will seek to recruit respondents who can provide rich description of: the PCT and newly evolving commissioning environment; the ethnic diversity and equality agenda; the research evidence base, its quality, accessibility and utility; and PPI. Respondents are likely to include: PCT managers involved in commissioning; managers within central DH directorates; Leads for specific relevant initiatives (such as DRE and Race for Health); clinicians actively involved in PBC; academics (particularly those involved with KT initiatives); SHA staff with a diversity and equality remit; and third sector stakeholder representatives (such as King’s Fund, Race Equality Foundation and local BME networks). Respondents will also be mixed in terms of their seniority, gender and ethnicity. Respondents will be contacted by email and, if necessary, by follow-up phone call. Following full consent, respondents will be asked to complete a short online questionnaire to capture background information. Respondents will then be invited to participate in a loosely structured interview either face-to-face or by telephone at their convenience. The interview guide (which will need to be prepared prior to ethics approval) will be piloted and refined prior to the first interview and this will ensure that the main topics of interest are covered while not rigidly determining the direction of the interview. Interviewees will be asked to comment on the role of research evidence alongside other forms of knowledge within the commissioning cycle and specifically in relation to tackling ethnic inequalities in health; factors that support or inhibit research evidence utilisation in this area; ways of supporting better use and examples of good practice; and issues that are poorly understood and would warrant further attention.

In addition to the Key Informant interviews, a small number (4–6) of ‘mini case studies’ will also be completed in Phase 2 with the intention of capturing information about instances of ‘good practice’ in relation to commissioning specific services for multiethnic populations. The rationale for these is that at a time of major restructuring of commissioning infrastructure there is a danger that elements of innovation and effective working in this area may be lost. Potential case studies will be identified through professional networks, and we anticipate a mix of local case studies (Sheffield/Leeds/Bradford) and some further afield. For each mini case study we will interview 2–3 key actors, either individually or as a group, and also review relevant documentation. Case study respondents will be asked to contribute general information similar to that sought from the Key Informants, but will also provide information specific to their own field of practice, describing how they have addressed the issue of commissioning for a multiethnic population, how various types of information have been brought to bear on this task, and the barriers and facilitators to the use of evidence, as well as other factors that may have supported or hindered an explicit focus on ethnic diversity and inequality.

Subject to consent, interviews will be tape-recorded. Interviews will be transcribed in full and soon after the interviews researchers will prepare detailed, holistic memos to record observations on the interview process as well as capture overarching themes. Ongoing reflection and aggregation of the interview memos will allow the research team to identify when data saturation is achieved. We anticipate 30–40 interviews, conducted by the Researcher, SS, GM and PCT co-researchers. Following completion and transcription of around 20 interviews, the Researcher (with support from SS) will establish a project database using the qualitative analysis package Nvivo which is ideal for managing large quantities of qualitative material and coordinating analysis across teams of researchers. Data analysis will follow an inductive, interpretive approach combining holistic, contextual analysis and indexing (Mason, 2005). In practice this means that interview transcripts will be subjected to both line-by-line coding and holistic ‘narrative’ analysis. The coding scheme will be developed for use through an iterative process involving line-by-line blind coding of a sub-sample of transcripts by several members of the research team, comparison, refinement and annotation. Once finalised, the coding structure will then be applied to all the interview transcripts and, through multiple ‘search-and-retrieve’ actions, information from across the range of respondents will be brought together for further theme building. This ‘code and compile’ approach will be complemented by the detailed memo writing for each interview which will use a consistent guideline in which themes running through each narrative, contextual information, and more interpretive comments (for instance regarding inconsistency or obvious omissions) will be noted. The Researcher and SS will lead the development of the analysis approach, but will work closely with GM and the PCT co-researchers to co-produce the final presentation of themes and claims. The findings from this phase of the study will be written up as a journal paper and a shorter briefing note. An internal project workshop involving all co-applicants will also be held to discuss the findings and identify key issues for shaping the case studies.

Phase 3 (Jul 2011–Mar 2012): In-depth Case Studies of 3 commissioning organisations serving Leeds, Sheffield and Bradford. Involving a minimum of: 36 in-depth individual interviews; 15 focus group discussions; 60 naturalistic observation periods; 45 documentary analyses across the three sites combined.

In contrast to some case study designs, we have not selected our case study sites to be exemplars of good practice in terms of research utilisation. Given the emergent nature of commissioning practices, particularly in relation to ethnic diversity and equality issues, such an approach would not be feasible or appropriate. Instead, we have selected our sites with the intention of providing sufficient variation to be able to compare and contrast commonalities and differences and thereby gain analytical purchase, but also to engender cross-fertilisation of ideas and mutual learning across the sites.

We have therefore opted for a regional focus and within this to include three PCTs and related commissioning organisations that – by virtue of serving populations with diverse ethnic profiles and having distinct organisational approaches – offer sufficient variety to support the generation of findings that will have transferability to a wide range of commissioning settings. Bradford, with its history of immigration from the Indian sub-continent, has long recognised itself as a multiethnic city and 24% of its population identified as belonging to an ethnic group other than the majority White British in the 2001 census. In contrast, Sheffield and Leeds had much smaller minority ethnic populations at the 2001 census – around 10% – and their public services have only more recently engaged seriously with the needs of these communities. Despite this, Sheffield is home to some long-established minority ethnic groups, including the Yemeni and Somali communities, and the Leeds population includes significant concentrations of Pakistani and Indian groups as well as smaller minorities such as Turkish and gypsies and travellers with particular unmet health needs. All three cities have experienced high levels of in-migration in recent years and now have both well-established and newer minority communities, with the pace of ethnic diversification being particularly marked in Sheffield. The choice of case study sites also offers the potential for exploring issues related to commissioning services for individuals and groups with varied migration statuses, socioeconomic resources and health profiles.

Importantly, all three PCTs have engaged in significant recent work related to achieving World Class Commissioning and to meeting the needs of black and minority ethnic groups, so that the current study has pertinence. NHS Sheffield has recently undergone a knowledge management review and is currently examining the ways in which qualitative evidence, and particularly patient experience data, can be effectively integrated with other forms of evidence. In addition, a recent Audit Commission review of health inequalities progress has prompted new work on BME populations. Both Leeds and Bradford & Airedale are members of Race for Health. Relevant initiatives in Leeds include the commissioning of community development workers through third sector organisations with a specific remit to consult with BME communities to feed knowledge into the commissioning cycle. In Bradford a number of commissioning areas are currently under review from an E&D perspective and there are several examples of innovative service design and delivery to meet minority ethnic needs. Not surprisingly, there are important differences in emphasis and approach between the three PCTs and related commissioning organisations in relation to issues of ethnic diversity and equality and these will ensure that a range of minority ethnic communities and related concerns will be explored during the case study work. For instance, it is likely that in Leeds some attention will be given to gypsies and travellers since this is a current focus, in Sheffield economic migrants and the Somali community are potential ‘groups’ of focus, while in Bradford we would aim to explore issues relating both to the well-established and very large Pakistani community as well as to a smaller, newer community.

Over a nine month period, the research team will work intensively across the three sites employing a range of methods. During the course of the case studies, the PCT co-researchers will act as Key Informants for their organisational contexts, playing the combined role of guide, assistant, interpreter and historian (Burgess, 1985). It is important to note that, in line with our Integrated KT approach, the details of data generation will be developed in consultation with stakeholders in each city and that the draft description below is based on preliminary discussions regarding what would be feasible and effective at generating the required data.

Given the current uncertainty regarding the shape of commissioning organisations of the future, we can not specify precisely what the case study units will consist of at this time. However, our intention is to focus on organisational units that are likely to have longevity so that study findings are perceived to be meaningful for commissioners as they move forward with work within the emerging structures. In each commissioning organisation, data generation will focus at two levels, using Black’s (2001) typology these are: [I] ‘Governance policy-making’, that is, the strategic, agenda-setting level, and [II] ‘Administrative policy-making’, that is the operational level, at which two focused areas will be identified for each organisation. The operational commissioning areas of focus (which may be defined by disease or service/care pathway) will be selected in consultation with stakeholders since it will be important to produce findings that are pertinent and timely. These are likely to be areas identified within existing commissioning plans as in need of service improvement, extension or redesign. However, priority will be given to areas for which the research evidence base is relatively rich in relation to minority ethnic needs and effective service interventions (e.g. diabetes, mental health). We will also seek diversity in terms of how the commissioning teams are constituted, and in particular the role that different directorates, including public health, play within these teams.

In each commissioning organisation, for both level [I] – agenda-setting and [II] – operational commissioning, data generation will begin with a comprehensive mapping of people, processes and partners (including identification of the timeline and cycle of activities and stakeholder analysis); essential given the diverse and evolving structures. Exploration at both levels will also include in each organisation: participatory workshops, documentary analysis, focus group discussions, in-depth follow-up work with 2–3 key managers (sequential interviews and naturalistic observation) and consultation exercises with BME forum/user groups.

We anticipate using participatory workshops early on during the case studies to gain a broad understanding of prevailing practices and competencies within teams and the organisations. These will employ prompting techniques that integrate and extend diagnostic tools developed for assessing research capacity (e.g. ARC for CLAHRC, Sarre & Cooke, 2009) and race equality or cultural competence (e.g. Mir 2008; Department of Health 2004; Dreaschlin, 1999; CRE’s SHA Race Equality Performance Framework, 2004). These will generate data that will begin to address RQ1 and 2 above, particularly relating to commissioning teams and organisational setting.

Interpretive documentary analysis (Abbott, Shaw and Elston, 2004) will be employed to identify and synthesise key themes from relevant documents. This analytical approach will enable us to identify different layers of explicit and implicit meaning. The identification and selection of relevant documents will be guided by the PCT co-researchers and other managers/commissioners. At the ‘governance/agenda setting’ level these are likely to include: JSNAs, Commissioning Strategies; Health Inequality Action Plans, Race Equality Strategies, Research & Development Strategies; broad level Equality Impact Assessments, external evaluations, relevant meeting minutes and background briefing documents that trace the origins and evolution of key strategy documents. We will explore: how key issues are framed and what knowledge sources have informed the articulation of these issues; what assumptions exist regarding the desirability or necessity of change and the possible routes of intervention and what knowledge(s) have informed these; who are the key stakeholders and what knowledge(s) they bring. At the operational level, we anticipate looking for signs that ethnic diversity and equality issues have been considered at a general level (e.g. do service specifications include interpretation/language support requirements, is monitoring data to be collected by ethnic group, are expected outcomes clearly specified with respect to ethnicity?) as well as in more specific ways (e.g. do service specifications stipulate particular models of care that have been shown to be more effective than standard approaches for minority ethnic populations?). Where these are evident, investigation will seek to explore the prompts to such inclusion and the possible role of different types of knowledge. Where these are not evident, investigation will focus on the reasons for absence. Templates will be designed to guide document review, though these will not be rigidly prescriptive. Documentary analysis will be carried out side-by-side with the interviews and group discussions (see below) so that we can develop a detailed understanding of the factors that fed into the production of these documents and subsequently how these documents circulate and impact practice. The documentary analyses will particularly generate data that will address RQ1 and also RQ2 in relation to commissioning teams, organisational setting and wider context.

In-depth follow-up work will take place with 2–3 key managers for the strategy level and each of the operational levels within each commissioning organisation involving sequential interviews and naturalistic observation (shadowing) in order to understand more about the individual factors that shape evidence use in this area. We follow Hunter’s (2005) advice to use reflexive, narrative approaches emphasising dialogue within the research context (since ‘prior and ongoing relationships with professional participants make it difficult and indeed undesirable for researchers to maintain silence’ (p149) in order to access more implicit understandings and discuss sensitive topics that might not easily be articulated within the interview setting. This element of data generation will particularly address RQs 2 and 3 providing rich information relating to individual managers, and commissioning teams as well as enabling refinement of emerging claims relating to the influences of organisational setting and wider context.

Focus group discussions will be held with senior managers and commissioning teams, two each if possible, part-way through each case study period. In addition to open-ended question prompts, a variety of prompting tools may be used including: problem tree exercises, vignettes, and ranking exercises. The design and focus of the group discussions will be informed by ongoing analysis so that they are used purposively to generate data to test emerging claims. These discussions will particularly aim to generate data that address RQ2 in relation to commissioning teams, organisational setting and wider context as well as RQ3.

In addition to the varied data generation activities with NHS managers, group discussions will be held with relevant representatives of BME populations and other stakeholders (e.g. PBC consortia) that have a significant role in the commissioning cycle. These discussions will provide information in support of answering RQ3 particularly in relation to the wider context and how this can help or hinder individual and organisational change.

Producing an integrated analysis of rich data generated through these diverse methods is clearly challenging both practically and theoretically. SS and GM, who will be closely involved in data generation across all three case studies, are both experienced in handling large quantities of qualitative data, as are KG and SN who will contribute to this stage of the study. The research team will use Nvivo to systematically organise and index materials from each of the data generation methods described above. As with Phase 2, analysis will combine ‘code and retrieve’ approaches across the data sources with holistic memo writing for each data source. Reflective journals will also be kept using a standard format by SS, GM, the Researcher and PCT Co-researchers. Regular analysis sessions will engage researchers and PCT managers in the inductive and interpretive identification and testing of emerging themes and ensure the ongoing iterative co-production of knowledge that is both credible and relevant to the end-users. Visual and diagrammatic methods of organising data will be used alongside text-based methods (e.g. using software Inspiration) and the generation and refinement of theory will be carefully documented to ensure transparent links between data and claims. In line with the theoretical model described above, the overarching approach to the analyses is informed by critical ethnographic perspectives in that we attempt to synthesise the traditional ethnographic focus on subjective meanings and beliefs of respondents with the insights gained from a broader structural analysis (Wainwright, 1997). While we give a central place to the ways in which managers describe their commissioning roles and their experiences of working within their organisations, we consider that such accounts require situating within an understanding of the broader socio-political structures that constrain and direct the behaviours of individual actors. In this way our approach can be seen to be ‘grounded’ in the emic perspectives of our respondents, but also guided by the theoretical perspectives outlined above.

Analysis of case study material from each site will first be conducted at a ‘within-case’ level. The focus will be on integrating, and triangulating, data across the domains of analysis (evidence, individual, team, organisation and wider context) in order to holistically describe the factors that shape evidence utilisation and to identify promising routes of intervention in support of more effective evidence use. Analysis approaches will include ‘process-tracing’ whereby data are integrated across sources to elucidate intervening processes and the exploration of implicit and explicit ‘predictions’ that should be observed if emerging claims are defensible. As Mahoney (2007) argues, detailed case studies of this type can provide substantial leverage for causal inference and, by virtue of developing rich contextualized knowledge, decrease the likelihood of overlooking key variables or mis-specifying the interrelations among factors of interest. Each case study will result in an internal project paper that will inform the development of the draft managerial/organisational tools, as well as feed into the cross-case analysis (see below). Tools development will begin towards the end of case study 1 and be ongoing throughout the case study period and into Phase 4.

When descriptions and explanations are complete for the within-case analyses we will move on to cross-case analysis, that is, the systematic comparison across the three sites to identify relational and substantive patterns. Such cross-case analysis is appropriate since the project aims to generate theory, and also practical tools, that can have applicability to a wider universe of commissioning contexts. While recognising the need for caution regarding the potential limits to extrapolation beyond the case study sites, we concur with Mahoney (2007) that good quality case study work can provide a strong position from which to make suggestions about the kind of modifications that might be necessary to extend causal theories to other settings. Initial cross-case analysis work will be conducted by the Researcher, SS and GM, followed by a participatory workshop including all the co-applicants and other interested managers in order to integrate findings across the settings and shape the form and content of research products including the supportive tools.

Phase 4 (June 2011–July 2012): Tools development, refinement and Testing and Development Workshops

This Phase overlaps with Phase 3 in that as case study work proceeds the team will start to develop potential tools and to seek feedback from respondents. Part way through this phase, SS, GM, the Researcher and the PCT Co-researchers will work together to further develop these supportive tools for use by managers and commissioning organisations, as well as to develop the format and materials for the Testing & Development Workshops. These draft tools and workshop materials will be circulated to all team members for input and will be discussed in Advisory and User Guidance Group meetings.

Three national-level Testing & Development Workshops will be facilitated. These events constitute a further round of data generation, analysis and synthesis, and not merely an opportunity to disseminate findings from the prior phases. The intention of these workshops is to test and further develop the explanatory models emerging from Phases 2 and 3 and to refine the practical, supportive tools in order to take account of stakeholders’ concerns and priorities and to maximise their transferability to a wide range of commissioning contexts. This Phase of the study thereby contributes data towards answering both RQ2 and RQ3 and directly feeds into the refinement of the practical tools that flow from the empirical and theoretical insights generated. Potential participants will be identified via professional networks including: the CLAHRCs, the NHS Institute for Innovation and Improvement and the Public Health Commissioning Network. Participants will be PCT managers involved in commissioning. Each workshop will include around 20 participants and we will seek to recruit diverse sample of participants in terms of the size and geographical location of their organisations, age, seniority, ethnicity and area of expertise. Additional participants will be included from key stakeholder groups that input into commissioning decisions relating to black and minority ethnic health including service user representatives from local LINks. Participants will be expected to have detailed knowledge and experience of the commissioning cycle within their organisation. All participants will be expected to complete preparatory work prior to the workshops which will include the completion of a short online questionnaire and a reflexive exercise based on the findings from Phases 2 and 3. This background information will then be drawn on in the workshop exercises. The workshops will be carefully facilitated and comprehensively documented so that the insights from these events can be effectively integrated with the data gathered through the earlier phases. Other recent work has successfully used similar ‘Think Tank’ approaches to generate understanding in the field of KT (Pettigrew et al., 2004).

Phase 5 (overlapping with Phase 4: Mar–Sept 2012): Wider dissemination and follow-on work

Team members will engage in writing for academic publications and delivery of dissemination seminars at stages throughout the project period. In addition, we allocate three months at the end of the project for completion of additional academic outputs and conference attendance (subject to conference timing, of course). Phase 5 will also put in place vehicles for increasing the sustainable impact of the project via the preparation of protocols for the piloting of the supportive tools within CLAHRC (SY) lead by KG and SS and promotion via ETN and other networks.

Collective research effort

Reaching multiple audiences; maximising reach:

The project will contribute significant outputs in a range of formats aimed at reaching the diverse set of stakeholders with interests in this area. The project will develop a comprehensive website to provide easy access to all project outputs. Team members will be active across the project life in delivering seminars, workshops and sharing work-in-progress to maximise project impact. Wide-ranging networks and complementary disciplinary and professional associations will increase the project’s reach.

Our primary audience is managers at various levels of seniority who contribute to the process of commissioning health services for multi-ethnic populations. Our Integrated KT model is well-suited to the development of research products that are accessible, appropriate and impactful. Preliminary team work has highlighted the need to identify and target not just the end-users of the research products, but the senior managers who shape organisational processes and structures and therefore determine whether or not such innovations are adopted and sustained. Working in partnership, NHS managers and university researchers will identify the key people and processes that need to be targeted in order to effect change; the appropriate language, style and content of research products; and the routes to introduction that are likely to be successful.

The project will also link closely to the NIHR CLAHRCs regionally and nationally, thereby capitalising on opportunities for mutual learning and dissemination. Several team members are associated with CLAHRC work and the present project is borne out of synergistic links with this programme. The project will also make use of relevant networks and organisations including: the Ethnicity Training Network; Minority Ethnic Health jiscmail (large virtual network); and Race for Health. We also intend to link with the NHS Institute for Innovation and Improvement at Warwick University that produces tools and resources to support commissioners and the Public Health Commissioning Network. The Project Advisory Group (see below) will ensure opportunities to enhance the usefulness and relevance of the research, to contribute to the collective research effort and to disseminate effectively to all stakeholders are maximised.

Our secondary audience is the research community, including researchers and the funders of research. The project will highlight the current inadequacies in the evidence base in terms of informing effective commissioning for black and minority ethnic populations. We aim to prompt more researchers to make their research inclusive of, and appropriate to, the health needs of minoritised groups. For researchers already working in the field of ethnic inequalities, the project will increase awareness of the barriers and facilitators to utilisation of research findings in this area. The project will provide a greater appreciation of the focus, content and format of research studies and products that are likely to make an impact; as well as give insights into the factors that might help to build relationships with commissioners that can enhance the contribution of research evidence to tackling ethnic inequalities in health.

Follow-on work – extending project impact:

CLAHRC (SY): The managerial and organisational tools developed by the project will subsequently be piloted in the NIHR CLAHRC South Yorkshire as follow on activity supported by existing funding from the CLAHRC. A total of 4 PCTs, including NHS Sheffield, are partners in the CLAHRC SY. Drawing upon the joint expertise of CLAHRC SY implementation themes on knowledge translation (lead KG) and evidence-based commissioning (lead MW) research products will be trialled and evaluated with strategic commissioners and managers from these PCTs. After piloting, the research products will be shared more widely across the other 8 NIHR CLAHRCs. KG as implementation lead for the SY CLAHRC has excellent links with the implementation leads of the remaining CLAHRCs to support this activity. Workshops will be hosted linked to CLAHRCs located in areas with an ethnically diverse population, for example Manchester, Leeds, Leicester, Birmingham, North London. This activity will be supported by CLAHRC (SY) funds and will occur following completion of the proposed project.

Ethnicity Training Network: ETN will also be an important conduit for the research products. The theoretical and empirical knowledge generated will be used refine the strategies and model of knowledge transfer currently used within ETN’s programme of work. In addition, the ETN will be an important route through which to promote and disseminate study findings and tools through its network of around 2,000 members, many of whom are leads for diversity within NHS settings.

Canadian links: Several team members have ongoing collaborative links with researchers and policy-makers in Canada, including: Gina Higginbottom, Canada Research Chair in Ethnicity & Health, University of Alberta; Zubia Mumtaz, Assistant Professor, School of Public Health, University of Alberta; Carole Estabrooks, Professor and Canada Research Chair in Knowledge Translation, University of Alberta; Jacqueline Tetroe, Senior Advisor Knowledge Translation, Canadian Institutes of Health Research. We would welcome the opportunity to extend the project focus to include comparative work in Canada should this be possible via the SDO programme.

Outcomes:

Tools developed from the study will enhance PCT managers’ and commissioners’ ability to draw on research evidence relating to ethnicity in health decision-making at both strategic and operational levels. Findings will support academics to draw on new knowledge about how to increase the impact of research on ethnic diversity and where to focus their efforts. The study will also equip Local LINks and service users with the knowledge to draw on the existing evidence base in lobbying for improved service provision and for research that fills current gaps in knowledge via the commissioning process.

Plan of investigation and timeline