Making Library & Knowledge Services Business critical

Editor's Notes

• #2: A bit of background I joined a PCT as Commissioning Librarian in 2008 and supported it through the hiatus of the Health and Social Care Act to a CCG and subsequent changes. In 2013 I as TUPEd over to a Commissioning Support Unit, but carried over my evidence support role, but for a larger footprint including many CCGs and the CSU itself. In the PCT/CCG I provided an embedded evidence service supporting service redesign and CCG authorisation through alerting services, team support and ad hoc searches. Critical here is embedded – I was part of project teams, attending meetings and submitting reports to the team in the same way a clinical librarian attends ward rounds and responding, both to verbalised requests but also proactively as well as guiding my alerting services. This activity has been highlighted by the KfH framework
• #3: Title taken from HLG plenary presentation from Patrick Mitchell HEE Regional Director, South of England “Knowledge for Healthcare Becoming Business Critical…. Making it happen” http://www.cilip.org.uk/sites/default/files/documents/louisegoswamipatrickmitchell.compressed.pdf He emphasised the importance of evidence from bedside to boardroom, but we tend to shy away from the boardroom. LKS clearly have a role to support evidence based clinical education and practice, and research, but there is an increasing discussion about evidence based policy and management decisions. Some LKS have been actively supporting management and commissioning decision making, but the profile of LKS support for EBP has been raised by the KfH framework. So I want to tell you something of the key research and learning supporting the development of library services for managers, my experiences, how LKS can learn from it.
• #4: The NHS is a business – first thing I was told at an induction course when I joined NHS. A business with a financial envelope and political masters. DH sets the agenda and budget - 17 policies including health and social care integration, NHS efficiency, LTC, public health, Cancer research and treatment, patient safety 27 agencies and ALBs – one of which is NHS England, NHS Digital, CQC, HEE, NHS Improvement NHS E mandate which sets the direction for the NHS and financial envelope for the following year. NHS England 2017/18 mandate there are 7 over riding objectives some of which will depend on development of STPs, with cross organisational boundaries. This translates into a range of business critical initiatives for NHSE the most important being STPs and Five year Forward View. But also seven day NHS, Carter Review, Francis report, and the “must dos” in the NHS Operational Planning and Contracting Guidance 2017-9. Just waiting for NHS E Business/ Delivery plan – due next week - to give direction for the Five Year forward View. These determine what is in the managers inbox over the next year. What are the key business activities in your trust? – Vanguards, IT initiatives, specialised commissioning, cancer treatment?
• #5: The person in the centre of NHS business is the manager – from the CEO to the project manager looking at reorganising or commissioning a service. Understand who is in the boardroom from the CEO to patient/public representatives
• #6: Find out what is business critical Specific issues eg A&E, services under development, CQUINs, co-commissioning, NHS Improvement, Keogh, vanguards, PACS, MDT, Carter, QIPP; HRG; 2WW; CCG, CSU, JSNA So if you are asked you understand the issues and ask sensible questions and tailor your services
• #7: With the activity around STPs and the disappearance of the commissioner/provider split LKS need to think about service development in the widest sense, including commissioning and service development.
• #8: We have to understand what managers mean by evidence. The research indicates that what we find runs counter to our training. Clinical research and practice is based on well established protocols of RCTs but how the service is organised on the ground which is determined by many factors - staffing levels, estates, number of patients, other available services, political pressures as well as finances.
• #9: So what are the questions - in my language A lot of work going on about developing services across traditional boundaries – in particular taking work out of acute into primary care, care closer to home, hospital at home, virtual wards, extended use of outpatients, wider use of consultants (outside acute).
• #10: Managers not usually trained in finding evidence – exceptions public health and clinicians. But in my experience GPs take their EBP hat off when they enter the boardroom. The research into info seeking behaviour always highlights how difficult it is to find the evidence. It is not conveniently placed or organised. Clearly commissioners rely heavily on colleagues and personal experience. Informal sharing is an important part of the commissioning process. They look for the evidence themselves and that means google and all of its pitfalls, but judicious use of google is a good way to get some of the evidence they need. Mailing lists / alerts – keeping ahead of the curve/horizon scanning are important NHS sources are constantly changing – think of NeLH, Specialist Collections, NHS Improvement (the old one), NHS III and the DH website itself. The exception is public health trained staff who have had training in finding and appraising evidence. But since the HSC Act and their move to LA they are one step removed from the informal commissioning discussions which does affect their influence. Most managers don’t think to ask libraries for this type of evidence, unless they have had previous contact with the library – a training course, induction etc. Finally- librarians too find it difficult to locate evidence for commissioners and managers.
• #11: The analysis of health managers’ information behaviour and use - replies from 2,092 managers in a survey 2009. Before any thoughts of Health & Social Care Act, reconfiguration of the NHS   Librarians/Inf Specialists Daily/weekly 10%; Yearly or less 46% Trust libraries/electronic resources Daily/weekly 29%; Yearly or less 28%
• #12: How the evidence is used follows from what we have found about how it is gathered. No nice clean pipeline of development, or PDSA cycle. Very much agrees with my experience in a commissioning environment. Decisions are not made in a single step. May decide on specific components based on the evidence but these are batted around and reinterpreted according to new discussions. There is no Right or Wrong, just Better or Worse and the variables are wide ranging – cost, workforce requirements, geography, patient experience.
• #13: Some of the research around how managers use the evidence once they have it. Consider the work by Gabbay around Mindlines.
• #15: Need to change the view of library services – in the same way that clinical librarians/outreach librarians have revolutionised library services. Get out of the library – be “in the room”. Does not mean literally in the boardroom, but you need to build the relationship with managers in the same way clinicians, so that you can be part of the corridor conversations. Training is of limited value. If librarians find this difficult with our searching skills, why would we expect managers to be able to do this. Our job is to make finding relevant evidence as easy as possible and easily digestible. In my view that means presenting it on a plate (within our competencies).
• #16: So if managers’ evidence needs are different to clinicians’ – what do they need? A study by Swann surveyed 345 individuals across 11 PCTs in 2010. - Demonstrated a plurality of evidence Clinical evidence we would all recognize, guidelines, clinical research, Royal Colleges, professional peer groups. Non clinical evidence – supporting evidence in terms of policies, toolkits, intelligence , benchmarking. Implementation Narrative resources –Include opinions, advice, stories, case studies. While clinical research usually aims to eliminate confounders and variables, these variables of setting are critical to understanding the workings of health services across different geographies. For example service availability, distances, workforce, and demography. You rarely get this level of detail when people describe services in research. Therefore case studies or talking to people may be the best way to understand the “evidence” behind a service. It is because of this spread of resources that LKS are not usually considered when looking for this type of evidence. LKS are linked to clinical journals, textbooks etc, not this “grey” literature. There is work to change that – Stockport Grey literature http://allcatsrgrey.org.uk/wp/
• #17: How are you going to find this evidence? HSJ (no print after next year). The key news resource Most commissioners/managers will get the daily news alerts. Their comms people should be keeping them abreast of the news and media stuff. Dig down to find the documents behind the story eg CCG board paper, report etc. Also helps up keep up to date with what is going on National policies -NHS E/ CQC /PHE/ NHS Improvement/ Public Accounts committee Expert bodies eg KF, Nuffield, Royal Colleges etc. Bibliographic resources Frontline research Magazines/board papers/ NHS Fab stuff – to find case studies Google – a key resource to dig into board papers and reports, much better than search engines on websites. Become a google expert.
• #18: Research says that for day to day business they want business style reports. And preferably before they know they need it. Managers want evidence presented in such a way that they can pick up the key points at a glance, can read a little more if it is interesting then look further using any links they are given. Look at Kings Fund reports – headlines in the form of bullet points, an executive summary and then the full report with references. Very different to clinical research reports.
• #19: Ranges from a single link to a fully synthesised report. Output format depends on the question and timescales.