The Philosophy Behind NIHR CLAHRC WM

It is sometimes said that if you want to understand the English then you need to understand their pantomime. To understand CLAHRCs you need to understand the role of matched funding. Before an application can be made for the £10m of NIHR CLAHRC research money it is necessary to raise at least that amount in the form of matched funding from the local services. Our particular CLAHRC receives £2.00 in matched funding for every £1.00 contributed by the NIHR. But what is this matched funding for? As we conceptualise it, matched funds implement the service changes around which academic study is conducted. These service changes involve staff time and so the bulk of the matched funds support clinical and managerial staff as they go about changing the service to support better quality care. NHS or local authority staff who are working on service change in collaboration with the CLAHRC are designated ‘Leadership Fellows’, in line with the ‘L’ in CLAHRC. So the matched funding is used to support Leadership Fellows in developing and implementing service change. The service change is necessary to make care more effective, safer, acceptable, efficient, and accessible. CLAHRCs therefore represent a collaboration between academics and service personnel as they go about the job of improving care. Academics often fall over their own feet when conceptualising these straightforward concepts, so let’s stick to basic ideas that everyone can understand. Improving care generally means bringing new knowledge into practice, so this whole process of changing the service to improve care can be called knowledge management / brokering. And there is a science behind the process of service change in support of improved care, sometimes called Implementation Science. By aligning service staff (funded by the service) and academic staff (funded by the NIHR), knowledge about what type of care is most effective / safe / acceptable / efficient, can be synthesised with knowledge about how to change services and local knowledge. But what form do these collaborations take?

The CLAHRC can respond to the service in four main modes:

1. Service staff may have a problem they want to fix and turn to the CLAHRC for advice. In this case the CLARHC helps service managers /clinicians to decide whether or how to intervene. For example, the local NHS sought advice on the role of community health workers in reducing the high perinatal mortality in central Birmingham. CLAHRC WM collaborator Christine MacArthur was able to tell service managers that this was unlikely to succeed on the basis of a systematic review of the previous evidence. However, she also pointed out that such a peer service was an unproven, yet plausible, intervention to reduce postnatal depression (and hence promote child development) in women at high social risk. This was the provenance of the successful ELSIPS (Evaluation of Lay Support in Pregnant Women with Social Risk) trial,[1] which demonstrated the effectiveness of such an intervention, especially in women at the highest social risk, such as young, single unemployed mothers.

2. The local NHS may have well formed plans in which case they may turn to the CLAHRC to evaluate the effectiveness of the implementation of these plans. For example, the Sandwell health authority invested about half a billion pounds in improving the fuel efficiency of social housing by investing in home improvements, such as more efficient boilers and better insulation. Our CLAHRC tracked the effect of improved thermal efficiency on hospital admissions and the resulting paper will be submitted imminently – watch this space.

3. The NHS may have already intervened. In that case the CLAHRC may exploit an opportunity to study the intervention retrospectively, as we have done to evaluate the effect of increasing specialist availability over weekends.[2]

4. The idea for an intervention may come from the CLAHRC academic team itself. In these instances the CLAHRC WM team and the service collaborate in the development and piloting of the intervention – a process sometimes called co-production. For example, CLAHRC WM collaborator Tom Marshall observed that many people who were eligible for statin treatment were not being offered a prescription and he conceived the idea of a case finding intervention based on data already recorded in the general practitioner’s computer system. He worked with commissioners and primary care teams to design an intervention to invite eligible patients to consider this treatment. This led to a stepped wedge randomised trial of case finding.[3]

The results of local pilot studies often form the basis of large-scale, competitively funded studies from NIHR HS&DR, or Programme Grant funding streams. For example, local evaluation of the computerised decision support programme at the University Hospitals Birmingham NHS Foundation Trust (UHBFT) led to collaboration between Prof Jamie Coleman and Prof Aziz Sheikh who secured a £2m programme grant to evaluate electronic prescribing systems of various types as they were rolled out in the NHS. The final report from this programme is pending. Like many CLAHRCs, we have an interest in the health economic evaluation of service change and have made a number of methodological innovations in this area. These include novel applications of Bayesian mathematical networks, which allow multiple sources of evidence, quantitative and qualitative, to be synthesised in order to estimate clinically and economically relevant parameters of effectiveness.[4] These techniques are being used to support Prof Julian Bion’s £2.5m HS&DR HiSLAC (High-Intensity Specialist-Led Acute Care) project.[5]

Setting up a CLAHRC is not always easy – the service and academia are not natural bed-fellows. Facilitators for successful collaboration include:

  1. Building trusting relationships.
  2. Not ‘over-promising’ – £10m is a nice research grant, but the West Midlands health budget is over £12bn per annum.
  3. Using flexible study designs tailored to the service imperative – our CLAHRC is an international leader in flexible designs, such as the step wedge design,[6] and its variations.[7]
  4. Involving patients and the public at every step and engaging them in the research through mutual exchanges of knowledge and ideas. In our CLAHRC, patient and public representatives are selected in a competitive process and we favour those who also advise the NHS on new services (see below).
  5. Prioritising issues that have large costs and commensurate pay-offs in prospect, i.e. ‘big ticket’ items.
  6. Selling a vision of a knowledge-based service and using examples to overcome scepticism. The News Blog you are reading is not ashamed to proselytise for CLAHRCs because we really believe in this model.
  7. Embedded senior posts in NHS organisations to make the human link between academia and service – we have established such posts in our major participating organisations.

— Richard Lilford, CLAHRC WM Director

References:

  1. Kenyon S, Jolly K, Hemming K, et al. Lay support for pregnant women with social risk: a randomised controlled trial. BMJ Open 2016;6:e009203.
  2. Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. Lancet. 2016. [ePub].
  3. Marshall T, Caley M, Hemming K, et al. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT. BMC Public Health. 2012; 12: 908.
  4. Watson SI, & Lilford RJ. Essay 1: Integrating multiple sources of evidence: a Bayesian perspective. In: Raine R, & Fitzpatrick R. (Eds). Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. HS&DR Report No. 4.16. Southampton: NIHR Journals Library. 2016.
  5. Bion J, et al. Stepping Up: A Phased Evaluation of the Impact of High-Intensity Specialist-Led Acute Care (HiSLAC) of Emergency Medical Admissions to NHS Hospitals. HS&DR – 12/128/17. 2016.
  6. Hemming K, Haines TP, ChiltonPJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ. 2015; 350: h391.
  7. Hemming K, Lilford R, Girling AJ. Stepped-wedge cluster randomised controlled trials: a generic framework including parallel and multiple-level designs. Stat Med. 2015; 34(2): 181-96.

 

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