Introduction
Methods
Data collection
Recruitment and data collection: interviews
Data collection: meetings
Data analysis
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Using substantive theories discovered in the realist review to develop CMOs based on the meeting and interview content.
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Using findings from the realist synthesis and content from meetings to inform the interview guide, which was updated on an ongoing basis.
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If a CMO was found in one content source but not another, the researchers re-read all the content sources in which the CMO was apparently not present to ascertain if the evidence for a CMO had been missed in the initial analysis.
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Pawson’s method of reconciliation: where apparently contradictory findings were found i.e. (partially) contradictory CMOs across the content sources, these were further investigated to by re-reading and re-analysing the content sources [36, 37]. Upon re-reading and re-analysing the content, it was usually discovered that what initially looked like a contradiction could be explained and reconciled by the development of more nuanced and refined CMOs.
Results
Overview of content from primary sources
Interviewees
Meetings
Contexts, mechanisms, and outcomes
CMOs that were identical or truncated versions of those in the realist synthesis
New CMOs based on interview and meeting content
‘Because I think with any incident reporting it can become a bit of…a kind of perception of a lot of process and very little return. So I think the one thing I would absolutely be pushing is that we show the difference that it makes by reporting incidents and really starting to encourage more of the lessons learned and why it makes a difference and why it’s important.’(Commissioner 21 – A, Meeting 21, Agenda item: Primary Care Quality Report).
‘It’s up to date, it’s user friendly, that’s why I think we tend to look at it and in a lot of ways because it’s driven by pharmacists who understand what are the things that we need to know…’(Commissioner interview 4, Deputy Director of Finance for a CCG).
‘…RightCare was a methodology that was being pushed on us from, from a central perspective as well and it was used as very crudely as benchmarking…without doing the bit about bringing in clinicians with you…it drove a lot of people to be… almost dis-interpreting the data i.e. finding where the loopholes were, why it was wrong….’(Commissioner interview 4, Deputy Director of Finance for a CCG).
‘So yes, somebody coming in to actually help you to work out your problems and you solve your problems works but I remembered yes, there was a lot of consultancy work at the beginning of CCGs and PCT days and it was highly ineffectual….it was actually a good way of throwing money at something and then and then finding that it did not fix the problem. The trouble with experts, they’re often not experts. They often haven’t actually worked in the field.’(Commissioner interview 14, clinical commissioner (GP).
CMOs refined based on interview and meeting content
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Portions of CMOs without any typographical emphases indicate convergence of findings, i.e. the portion of the CMO identical to the synthesis.
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Bold text indicates a new finding compared to the synthesis.
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Italics indicate a complementary finding, i.e. a similar finding to the synthesis.
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Crossed-out text indicates information that was present in the synthesis but is not present in the meeting or interview CMO (note: where complementary findings are present, italics are used in lieu of crossed-out text, since the findings are sufficiently complementary/similar).
Category | CMO # | Interviews | Meetings |
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Steps of the commissioning cycle | CMO 24 | If commissioners want to identify commissioning priorities (C) they may consult data as a starting point (O) since they believe they are useful (M) | Silence (CMO not present) |
CMO 25 | If commissioners believe that clinicians or service providers are not aware their performance is below average (C) and they do not want to be perceived as ‘judgemental’ or ‘performance managing’ they may share data with them in the hope of stimulating improvements (O) because of a perception that sharing data can empower clinicians or service providers to come up with solutions (M) | If commissioners believe that clinicians or service providers are not aware their performance is below average (C) they may share data with them in the hope of stimulating improvements (O) based on the assumption sharing this data may trigger discomfort, pressure, and awareness and therefore improvements (M) | |
Characteristics of data | CMO 26 | If commissioners have access to combined datasets (C) they will be more likely to use them (O) because the data are useful (M) and because commissioners can gain a fuller understanding of the patient journey (M) and because the data facilitate integrated commissioning (M) | If commissioners have access to combined datasets (C) they will be more likely to use them (O) because the data are useful (M) and because commissioners can gain a fuller understanding of the patient journey (M) because the data facilitate integrated commissioning (M) and because they have reassurance that the information is comprehensive (M) |
CMO 27 | Presenting key pieces of data in a succinct, visually appealing, and easily digestible manner to commissioners (C) can increase the likelihood the data will be used (O) since this increases their engagement with and understanding of data (M) | Silence (CMO not present) | |
CMO 28 | If commissioners have access to flawed or imperfect data they understand the limitations of (C) and this is the only type of data they have access to (C) they will still try to use the data (O) because they can adapt them in ways that are useful while taking into account the data’s limitations (M) and they believe this is better than using no data at all (M) and the data make decisions more defensible (M) | In a context where commissioners have access to ‘imperfect’ data they understand the limitations of (C) and this is the only type of data they have access to (C) and/or they have a commissioning issue they (urgently) want to address and/or (C) they feel they have an obligation to use the data (C) they will still try to use the data (O) because they can adapt them in ways that are useful while taking into account the data’s limitations (M) and they believe this is better than using no data at all (M) | |
CMO 29 | Having a data champion within the commissioning team support and promote the usage of data in commissioning decisions (C) can increase the usage of data (O) because the data champion can increase engagement and persuade people to use data (M) and because commissioners are more receptive to communication about the importance of data if it comes from a team member (M) | Silence (CMO not present) | |
Commissioners’ capabilities, roles, perceptions, and intentions | CMO 30 | If commissioners want to persuade others about their commissioning proposals (C) they may (selectively) use data to support their proposals (O) due to a perception that they are a form of evidence that are ‘objective’ and can increase the legitimacy of proposals (M) | If commissioners want to persuade or reassure others about their commissioning proposals (C) they may (selectively) use data to support their proposals (O) due to a perception that it is a form of evidence that is ‘objective’ and can increase the legitimacy of proposals (M) they may stress that these are based on data (O) since commissioners believe data are useful to advocate and justify their proposals (M) |
Interpersonal relationships with and perceptions of external providers | CMO 31 | If commissioners perceive external support to be able to provide different or new skills, data, or additional capacity (C) commissioners will be more inclined to use the data and outputs they produce (O) because they are perceived as novel and useful (M) and the commissioners believe this is a worthwhile financial investment (M) | Silence (CMO not present) |
‘So we know what areas for example we’re an outlier in in terms of usage and in terms of cost and those things. What we found with that kind of data is, it doesn’t necessarily tell you where you could make, it tells you the areas to look at but you usually need to do a bit more digging to understand what it is that the data is telling you’.(Commissioner interview 15, Manager)
‘I think sharing the data with them and even if it’s on a one-to-one basis I think that was the most powerful thing before yeah so I think I think it can sometimes the messages can sometimes get lost in all the messages that are out there so I think actually having very specific data around very specific practices whilst it’s not comfortable I think absolutely does it does get action.’(Commissioner 8-B, Meeting 8, agenda item: antibiotic prescribing).
‘you take a document and it is pulled together by people who really know how to take data and how to set up a document, people look at that and go, “Oooh.” They’ll make their decisions on, ‘Is it easy to read? Is it well presented? Is it a, a glossy document?’… and it’s very visually helpful and to be perfectly honest to try and get people to understand things, if you can’t put a pretty picture in front of them it just doesn’t work. Give them a table of data and numbers and they will cringe. Give them a pretty picture in a diagram and they’re all happy…’(Commissioner interview 10, Director, CCG).
‘This is something that the team have been working through this hasn’t been done just from a management perspective so to give the committee that reassurance: this has very much been driven through looking at the data with partners that we’ve been working with around population health.’(Commissioner 18 – A, Meeting 18, agenda item: primary care strategic priorities).
Category | CMO # | Interviews | Meetings |
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Characteristics of data | CMO 32 | When data are not captured and presented in an interoperable way with consistent definitions (C) commissioners will have difficulty using them (O) because they have difficulty drawing conclusions (M) and doubt the data’s credibility (M) and have difficulty following the patient’s journey (M) | When data are not captured and presented in an interoperable way with consistent definitions (C) commissioners will have difficulty using them (O) because they have difficulty drawing conclusions (M) and doubt the data’s credibility (M) |
CMO 33 | In a context where commissioners suspect that commissioning data are inaccurate or contradictory (C) they will not use them in commissioning decisions (O) and may seek alternative sources of evidence, including qualitative information (O) because they do not trust them (M) and have difficulty drawing conclusions (M) and they fear they may be challenged and lose credibility (M) | In a context where commissioners suspect that commissioning data are inaccurate or contradictory (C) they will not use them in commissioning decisions (O) because they do not trust them (M) and have difficulty drawing conclusions (M) | |
CMO 34 | In a context where (clinical) commissioners find that the data available contradict or are in tension with their experience and knowledge (C) commissioners may become skeptical of the data (O) because they are mistrustful (M) | In a context where (clinical) commissioners believe there is misalignment between data and their own clinical experience or information received from other clinicians (C) commissioners may become skeptical of the data (O) because they are mistrustful (M) | |
Commissioners’ capabilities, roles, perceptions, and intentions | CMO 35 | In a context where commissioners are subjected to financial pressures (C) they may choose to make commissioning decisions based on little or no evidence (including data) including at the expense of using data related to potential (clinical) improvements (O) because they feel obliged to prioritise financial issues (M) | Silence (CMO not present) |
Discussion
Summary
Strengths and limitations
Comparison with existing literature
Implications for research and practice
Recommendations | Examples of specific activities based on interview and meeting content | Informed by CMOs |
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Facilitate integrated commissioning | • Provide combined datasets where possible. This could include e.g. combining datasets from primary and secondary care, or combining NHS datasets with data related to inequalities such as housing or income data • Ensure data are aligned with new priorities around integrated care | CMO 26 |
Facilitate relationships with external providers of data | • Allow commissioners to work closely with external providers of data (analysis) to foster trust and co-production • Involve commissioners in the design, management, and, if possible, procurement of data-driven projects involving external providers | CMO 19, 23, 31 |
Encourage commissioners to champion and promote (new) data | • Designate a data champion internal to the commissioning committee • When introducing new data to commissioners, ask a member of the committee to introduce them where possible, and ensure commissioners’ potential reservations are taken seriously | CMO 21, 29 |
Facilitate commissioners’ understanding of data | • Distil key data in visually compelling ways • Ensure definitions and coding of data are as consistent as possible, and inform commissioners of any deviations | CMO 27, 32 |