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What is evidence?

When making decisions, commissioners need to consider a range of different types of ‘evidence’ –

Research papers, guidelines, evaluation, population and surveillance data, policy, health needs assessments, activity data, feedback from stakeholders, patients, carers and the public. This Guide supports commissioners to access evidence from range of sources but primarily focuses on evidence from research.

Commissioners face similar challenges to clinicians in applying evidence, so it is appropriate to apply principles from Evidence Based Medicine (EBM) into the commissioning setting.

But there is a key difference: commissioners are interested in decisions relating to large numbers of the population (eg a service for patients with heart failure) whereas clinicians are working with individual cases.

Hierarchy of Evidence

In research (and in Evidence Based Medicine), there’s a recognised model that can help you consider the quality and reliability of evidence. The Centre for Evidence-Based Medicine (CEBM) at Oxford University has more details – go to the CEBM website.

Systematic Reviews are often seen as the most reliable source of evidence. In commissioning it is rare that a systematic review or randomised controlled trial exists to support you in your decision making. These gaps in the evidence base need to be highlighted and shared with academic institutions and other organisations involved in evidence (eg the NIHR) so they can be addressed.  Currently in commissioning, evidence from a range of sources, reflected in the lower tiers of the hierarchy, will be more commonly available.

When looking at types of evidence you should aim for those that are as high up the pyramid as possible as these are considered to be of greater quality.

Evidence Culture

Evidence informed commissioning should fit within an organisation’s wider cultural landscape, to become ‘the way things are done’. The organisation’s ‘culture’ represents beliefs, values, practices and behaviour. It is complex and can influence whether an evidence informed approach to commissioning is adopted; it also shapes the form it takes.

Influencing the culture

A key enabler in the strengthening of an evidence and evaluation culture is good access to relevant evidence; this toolkit can help guide commissioners towards this. Public Health departments within the Local Authority provide expert support in accessing and using evidence and contribute to a growing evidence culture. The Joint Strategic Needs Assessment (JSNA) is a key resource that provides an evidence based overview of the changing health and wellbeing needs in your locality. This can be accessed via your Public Health team – see Contact.

This short video highlights the impact of finding and using evidence, where to look to find it and real world top tips, from commissioners and GP Clinical Evidence Fellows working across the West of England.

Additionally, there are a number of key initiatives in place in the West of England that contribute to getting evidence or knowledge from its source and into practice, known as knowledge mobilisation.

Knowledge mobilisation is defined as ‘making knowledge readily accessible and useful to individuals and groups by developing ways to work collaboratively’ (Health Information Research Unit). Simply, knowledge mobilisation is about sharing knowledge, often between disparate groups. A knowledge mobilisation initiative has been trialling in Bristol for three years, developed jointly between BNSSG Research and Evidence Team, the University of Bristol and the University of the West of England (UWE) – this has taken the form of a Knowledge Mobilisation Team but other roles that also contribute to promoting knowledge mobilisation are now being established:

Knowledge Mobilisation Team

This team foster collaborations between commissioners and researchers to encourage commissioning-informed research and research-informed commissioning. This initiative is led by Professor Nicki Walsh, Professor of Knowledge Mobilisation and Musculoskeletal Health at UWE. Nicki was appointed in July 2016. Her role is to bring together academic, clinical and commissioning colleagues to develop and promote knowledge mobilisation culture across the region.

For further information on local knowledge mobilisation initiatives, please contact

Embedding Evidence Culture throughout the Commissioning Cycle

1. Strategic Planning

Service Evaluation – Visit our Evaluation Toolkit

How to apply in practice:

  • For reviewing service provision against commissioning objectives and success criteria for a specific service.
  • Assessing service outcomes to understand patient and system benefits in line with the service specification.
  • Deciding priorities for improvement.

Commissioning Intelligence Model – See: Commissioning Intelligence Model

How to apply in practice:

  • For securing cross section of data types and sources to inform priority setting.
  • Part of any needs assessment to determine health needs of the local population.
  • Identifying gaps or deficits in quality, performance, value or outcomes.
  • Confirming where quality, performance and outcomes are strong.

Review of Evidence: Application

  • Use of the Joint Strategic Needs Assessment (JSNA) as a key source of evidence to inform priorities – via Public Health.
  • Horizon scanning health service research that may influence both national policy and local strategy.
  • Reviewing best practice evidence against commissioned models of care.

2. Procuring services

Evidence Appraisal (using PICO to focus your questions for evidence searches in the ‘Identify’ step of the Evidence Cycle)

How to apply in practice:

  • To inform the design/re-design of services including service models and patient pathways.
  • In the consideration of options for change and available evidence to support preferred option.
  • Informs decisions on what to commission at macro, meso and micro levels.

Service Specifications and Contract Formats

How to apply in practice:

  • Place explicit requirements on providers to promote patient participation in research studies, deliver evidence-based clinical care and evaluate their service delivery. Download a useful guide.
  • Ensuring that contracts are in place to hold providers to account.

3. Monitoring and evaluation

Service Evaluation – using the Evaluation Toolkit: Application

  • Evaluating whether changes to the way in which services are commissioned have delivered the expected benefits.

Commissioning Intelligence Model: Application

  • Consideration of a broad range of data types to monitor delivery of commissioning plans.

“Research can do more than contribute to better decisions – it can change the way we think about issues or problems and stimulate new and different ideas about services. In short, it’s vital to our capacity for innovation.”

Professor K Walshe
Associate Director of the National Institute of Health Research

“Evidence based medicine is the integration of best research evidence with clinical expertise and patient values”

Sackett D et al
Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1