Evidence-based policy-making: the view from a commissioner


Rachel Anthwal, Delivery Director at Bristol Clinical Commissioning Group

Date: 10 April 2017

I have always been of the mindset that to be the best commissioner I can, I need to use the best available evidence, information and best practice from across the country and abroad. But I am not sure I am typical as a commissioner.  As commissioners we are influenced by a vast range of competing factors. Some of these are:

  • clinical leads having a sole interest / solution to a problem they encounter which usually no amount of counter research evidence can shift
  • financial architecture – we have ‘payments by results’ and block contracts, which means transforming services and pulling the money out of one healthcare provider and putting into another, such as from an acute hospital into community services, is complex and fraught with difficulty
  • the many and varied competing priorities CCGs encounter – currently we have locally Sustainability and Transformation Plan (STP) formation and delivery; The Quality, Innovation, Productivity and Prevention(QIPP) Programme; turnaround and merging of our exec team with two other Clinical Commissioning Groups (CCGs); CCG assurance; performance of constitutional standards
  • the state of NHS finances - many CCGs are in deficit, or at the very least have extreme cost saving requirements year on year.
  • Local, national pressure groups or local councillors / committees

Research evidence is one of these factors, of which I value highly, but it doesn’t always help us out as commissioners. RCTs are not often applicable to pockets of our population. In addition research often doesn’t answer specific problems, e.g. is it possible to expand the patient cohort and get positive results for a population? Research often offers answers for healthcare providers and clinicians easier than commissioners, as it is more black and white – is drug A better than drug B? As commissioners, we have thornier issues, such as what one or two interventions are going to make the greatest impact for the population we serve? Is it affordable? How do we implement it effectively?

Another factor which often is overlooked by researchers is implementation which is complex even when the research evidence is clear. An example of this would be anticoagulation for patients with Atrial Fibrillation to prevent stroke. Despite knowing we should make this happen as commissioners, the research doesn’t help us overcome some of the practical hurdles to make it happen because:

  • We rely on GPs to implement this. But this is more work for GPs who are on a block budget held by another commissioner (NHS England), so we have no levers to make GP practices implement.
  • Which drug do we use to anticoagulate? Can we afford the NICE approved drug?
  • Will people diagnosed adhere to the treatment regime; if not how can we best ensure this happens?
  • If implemented, this could tip over our prescribing spend on the best drug for these patients, but we won’t see the cost savings as we are counting ‘strokes avoided’. So we won’t save any actual money on the balance sheet. This makes justifying the proposed change even harder.

In summary, our job as commissioner is to change systems (many and varied) to improve care - despite being up against people’s views and beliefs, payment systems, competing priorities and time pressure. I firmly believe that research evidence, although not perfect, can help us make better decisions. I would also, however, implore researchers to come and talk to us, to understand our pressures, our areas of worry, and help us build research evidence that answers our commissioning questions, with us.

For more information about the working world of commissioners, please see ‘evidence-based policy-making and the art of commissioning’ -

Rachel Anthwal

Delivery Director at Bristol Clinical Commissioning Group.

The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health and Social Care.
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    Rachel Anthwal, Delivery Director at Bristol Clinical Commissioning Group, discusses the importance of using research evidence in commissioning decisions, as well some of the challenges of doing so.
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    Rachel Anthwal, Delivery Director at Bristol Clinical Commissioning Group

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