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Salway S, Turner D, Mir G, et al. Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers. Southampton (UK): NIHR Journals Library; 2013 Dec. (Health Services and Delivery Research, No. 1.14.)

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Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers.

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Chapter 4Commissioning in practice: organisational structures and cultures

Introduction

As described in Chapter 2, the case study work was intended to provide an in-depth look at commissioning practice at strategic and operational levels, involving the integration of data on a number of levels and providing a detailed contextual analysis of actions and relationships. Although the case studies provided further data of relevance for research questions 1 and 3, they were particularly intended to focus on research question 2.

Research question 2: how does organisational context shape the mobilisation and utilisation of knowledge relating to ethnic diversity and inequality?

  • How often, and at what stages, do managers apply research evidence relating to ethnic diversity and inequality in their commissioning tasks?
  • How are commissioning teams constituted and organised? How does this impact on evidence use?
  • Who is seen as holding expertise and insight in relation to ethnic diversity and inequality? Why?
  • To what extent do PCT commissioning organisations have explicit models, structures, processes and objectives that support the mobilisation and utilisation of evidence? Do these consider ethnic diversity?
  • In what ways does managerial behaviour support and encourage, or deter, the explicit consideration of research evidence relating to ethnic diversity and inequality within commissioning teams?
  • In what ways do the available infrastructure and resources support and encourage, or deter, the explicit consideration of evidence relating to ethnic diversity and inequality within commissioning teams?
  • How do national, regional and organisational policy priorities inter-relate to shape the mobilisation and utilisation of evidence in this area?

Although the data collection activities were nominally undertaken as part of either the strategic-level or the operational-level case studies in each study site, in practice there was overlap in the material generated. For instance, many of the interviews conducted for the operational-level case studies also provided rich insights into the wider workings of the organisations, whereas observation of strategic-level meetings revealed information not only about organisational priorities and structures but also about how individual actors might exert their own agency in responding to them. Therefore, although the findings are organised into two chapters – Chapters 4 and 5, with the current chapter focusing on organisational-level structures and cultures – we draw across the range of data generated as appropriate.

The case study work provided confirmatory evidence in support of many of the themes highlighted by the key informant interviews, and gave more detailed illustration of how these factors played out within the operational settings of the three PCTs. In addition, this stage of the project provided further insight into how commissioning work is achieved in practice, and in particular the factors operating at different levels to shape and constrain the use of research and other forms of evidence in commissioning in general as well as in relation to ethnic diversity and inequality.

We therefore take the key themes highlighted from the key informant interviews in Chapter 3 as a starting point and use summary tables to illustrate the ways in which the case study materials support or refute each of these, providing selective commentary to highlight additional themes not previously highlighted by the key informants.

Descriptive overview of the three case study sites

As described in Chapter 2, our case study work was centred on three PCTs: NHS Sheffield, NHS Bradford and Airedale and NHS Leeds. The case study sites were selected on both practical and theoretical grounds, providing both the possibility for fruitful networking and learning across the partner organisations and the opportunity to observe commissioning practice within a range of contexts. Table 2 provides a sketch of these three PCTs, illustrating some important commonalities and differences.

TABLE 2

TABLE 2

Case study PCT general descriptors

Table 3 provides a summary of the strategic-level data collection activities undertaken in each of the three sites. In each case the bulk of our data collection involved individuals and groups working within the PCTs, but, recognising the importance of partnership working and joint commissioning arrangements, we also engaged with relevant individuals and groups within the local authorities, particularly social care commissioners, as well as managers within NHS provider trusts and the third sector.

TABLE 3

TABLE 3

Summary of strategic-level data collection across the case study sites

Case study work began in each site in phase 2, with a series of key informant interviews with individuals identified as having wide experience of commissioning work within their own cities. In phase 3 we employed a range of methods including interviews, structured observations and documentary review to enhance our understanding of strategic-level work in each site. The focus here was on understanding the organisational structures and cultures operating within the three PCTs to shape commissioning work. Opportunities for data collection varied across the sites, reflecting different structures and networks, but multiple points of contact were used in all three sites to ensure a range of perspectives. In addition, the implementation of the Equality Delivery System98 and the production of Equality Objectives took place during the study period and were investigated across all three sites. Further, the co-researchers engaged in regular structured reflection, completing reflective diaries or debriefing exercises with the university researchers, across the whole study period.

Commissioning aims, organisation and impact

Table 4 illustrates that many of the general themes relating to health-care commissioning highlighted in the national key informant data in Chapter 3 were reiterated in our strategic-level case study work.

TABLE 4

TABLE 4

Strategic-level analysis: health-care commissioning aims, organisation and impact

In particular, the strong focus on curbing expenditure, particularly through reducing secondary care usage, and the dominance of national drivers, particularly around quality and the NHS Outcomes Framework,93 were clearly evident. Importantly, however, there was evidence to suggest that not all national drivers and targets are responded to with the same degree of senior-level direction and co-ordinated action across the organisation. Differential organisational responses appear to relate to perceptions of both achievability and accountability, with the following questions being raised: Is the target reasonable? Is this really within our remit and responsibility? How closely are we being monitored on this area of performance?

The case studies provided confirmation that commissioning has had limited impact on reshaping health-care provision and that needs assessment work and commissioning action are not as closely connected as they should be. Nevertheless, we found an explicitly transformational aspiration in two of the three study sites, at both organisational and individual level, and the third had begun work to move towards a more transformational approach. The case study work added to our understanding of factors that limit transformational potential by illustrating the fragmented way in which commissioning work is organised and delivered. We found that transformational projects tended to be undertaken in relative isolation from each other, focusing on particular disease pathways or service areas, often working within fixed ‘envelopes’ of spend. This often appeared to be a pragmatic way of managing many competing demands and vested interests both within and outside the PCT, as well as negotiating some degree of change within elements of existing service configurations perceived to be fixed. Key actors were well aware of these limitations and there were some attempts under way to take a more holistic approach – to pool budgets and address the interplay of different elements of service provision in the form of larger programmes of transformational work. Importantly, there was also variation across the three sites in the extent to which commissioning options were perceived to be constrained by powerful NHS provider trusts.

The three PCTs were structured and organised quite differently. In two of the three PCTs there was a stronger internal sense of the whole organisation being a ‘commissioning organisation’, whereas in the third there appeared to be a more disjointed approach with separate teams not necessarily having a clear sense of their work contributing to the broader commissioning agenda. The role of public health within health-care commissioning varied significantly. When public health was closely engaged across the commissioning cycle and not confined to needs assessment, a strong population perspective and inequalities focus (although not necessarily ethnicity focus) was evident, again chiming with the earlier key informant reports. However, even when public health was well integrated into the core health-care commissioning work, there were evident tensions, with public health priorities at times being seen as conflicting with other drivers, and some public health staff expressing the feeling that they had to battle to have their objectives reflected in strategies and provider contracts. (Respondents have been identified by their current organisation and broad role. More specific job titles and case study site have been avoided to preserve anonymity.)

But if you talk to people in strategy they’ll, they’ll talk about public health as the biggest financial leak that there is, do you know what I mean? Because it’s sort of like we can’t afford what public health want, public health drive all of this, you know . . . woolly stuff that we can’t afford. You know what I mean, and that’s, you’ve got to understand that there’s always those different perspectives, so there’s XX there going well we need more, we need health checks rolled out, we need this, we need that, we need all of these health improvement workers doing all of this lovely woolly work and taking people out on walks to make them healthy and stuff, and we’re here sort of going we can’t meet our A&E [accident and emergency] targets because we can’t afford the doctors and we’re struggling with contract neg . . . It’s the balance, you know, XX is there with his performance, we need to be performing, what do we need to do to up performance.

PCT commissioning manager

In relation to involvement of wider stakeholders and patients and the public within commissioning, the case studies found that these elements were recognised as important across the three sites but not yet operationalised effectively.

In addition to the themes in Table 4, the case study work also revealed the importance of local drivers and the challenge of responding to national directives within the context of local priorities and opportunities:

There tends to be top-down directives around what services should look like and a lot of obviously NICE guidance and so on. As well as that we would, you know, draw on for that, so it’s to oversee the commissioning cycle within [the city], but in that, in the context of national policy and priorities, and local policy and priorities, because obviously we have different, you know, configurations of service, and particular opportunities to improve things locally which aren’t so nationally determined. But, so in terms of that commissioning cycle it’s about understanding the needs, understanding how we’re currently meeting those needs with our current models of service, how we might improve those, reviewing the performance . . . we do have quite a big focus on outcomes . . . so we regularly would look at key indicators that we’re responsible for, some of which we have, you know, national targets for, others we’ve determined local targets.

PCT senior public health commissioner

Organisational structures and influences on ethnic diversity and inequality work

As illustrated in Table 5, the case study work tended to confirm and further illuminate the organisational structural and cultural factors identified by the national key informants as barriers to attention to ethnic diversity and inequality. The consistent message was that this remains a marginal, poorly resourced and, at times, contested agenda within commissioning.

TABLE 5

TABLE 5

Strategic-level analysis: organisational structures and influences – ethnic diversity and inequality work

The lack of direction from the DH and strategic health authorities, and a lack of senior local leadership on this agenda, was confirmed in all three sites. In particular, the absence of any kind of performance management was clearly reflected at local PCT level. In contrast to the highly developed infrastructures for monitoring quality and finances, the E&D resource was found to be low (particularly in case study 1) and poorly connected to these other strands of work. Importantly, in all three sites respondent reports and our observations confirmed that equality impact assessments were often poorly carried out, were detached from core commissioning processes and lacked impact or follow-up work:

What they tended to do was say, ‘OK, we’ve done our impact assessments, they’re on the website, that’s it, we’ve done it’. Whereas for me, if people, organisations really understood what impact assessment is about, it’s about a process.

PCT E&D manager

We’d been doing equality impact assessments without any sort of external input.

PCT E&D manager

We have had a process of equality impact assessments, but it was a fairly feeble process, it felt like, because I remember, in that there was no real follow-through.

PCT senior public health commissioner

Key documents, such as those relating to quality assurance, were found to lack any mention of equality. Furthermore, in all three sites we found poor specification of ethnicity within health inequalities strategies and targets.

In the absence of systematic and regular reviews of performance against equality standards, attention to ethnic diversity and inequality issues was largely found to be reliant on the interest and commitment of particular individuals (as discussed in Chapter 5). However, focused work was occasionally prompted by local patterns of service use by minority ethnic people, particularly those that were perceived to be problematic. Even more rarely, important aggregate outcome indicators were affected by rates within minority ethnic groups. One example of this was high infant mortality rates among the Pakistani population, prompting particular attention by public health commissioners. However, it should be noted that there were significant concerns among local stakeholders in two of the sites regarding the nature and adequacy of the response to this issue.

Looking across the three sites also confirmed that a range of obstructive discourses were in operation, with attention to ethnic diversity and inequality at times being explicitly blocked or undermined and at times being overlooked or sidelined by arguments that construct such a focus as unnecessary, inappropriate or too difficult. For instance, in one site a detailed strategy document focusing on the health and social care needs of ‘BME adults’ was prepared by mid-level staff from both the PCT and the local authority who had E&D as part of their role, but it was never officially adopted by the PCT despite considerable efforts to lobby senior leaders. Another example of obstruction found in two of the sites was the expressed need to focus on other equality groups and the implicit or explicit suggestion that sufficient focus had already been given to ethnic inequality issues. Importantly, evidence from all three sites confirmed the importance of strong leadership, with past gains being lost when senior staff committed to the agenda had left the organisation or moved roles because of restructuring.

An unhelpful reliance on external consultants to undertake ethnic diversity and equality work was seen but did not appear to be as much of a problem as the lack of structures and processes to connect in-house expertise to core commissioning functions. However, there were isolated pockets of good practice and a willingness at an individual level to enhance skills and confidence in this area, potential opportunities that largely remained unsupported by the wider organisational context. Nevertheless, in all three sites a lack of ethnic diversity among staff was evident, particularly at higher levels, and respondents felt that this undermined a more consistent focus on this agenda.

Despite this generally rather gloomy picture, our investigation of the Equality Delivery System and the Innov8 diverse leadership programme did suggest some potential avenues for progress towards a more enabling strategic environment, and these are discussed in more detail in Chapter 6.

Organisational structures and influences on evidence use generally

Table 6 confirms that the following themes from the national key informant interviews were clearly reflected in the case studies:

TABLE 6

TABLE 6

Strategic-level analysis: organisational structures and influences on evidence use generally

  • data use on spend and quality indicators was supported by strong internal infrastructures
  • public health involvement in commissioning tended to enhance the use of evidence (particularly population-level data)
  • there were clear expectations that commissioners would be aware of, and their work would reflect, national-level synthesised research evidence in the form of NICE guidance and policy documents, and there were processes in place to support this (e.g. regular circulation of new documents)
  • there were few structures or processes that routinely connected commissioning activity to primary research evidence
  • there was a lack of local evidence generation or sharing through the evaluation of interventions or service redesigns.

The following quotes from a local key informant clearly illustrate the contrasting organisational support and expectations around the mobilisation of nationally synthesised evidence compared with other, primary research evidence:

So we have a mechanism in this organisation for circulating and distributing new evidence that’s published, so our library service sends a daily bulletin around every day that says NICE have just published this, this has just come from the department, you know, whatever it might be . . . so that’s one mechanism, which is kind of very much a kind of top-down stuff . . . It’s kind of, the purpose of NICE is to make sure that we’re, we, commissioners and providers, are informed of research, which tends to be very clinical research, doesn’t it, the NICE stuff . . . the guidance and appraisals and new technology, all that stuff comes into the organisation. And that tends to be well-implemented I think, because there’s a clear route, we keep track of the NICE stuff that’s been published, and we have a mechanism for keeping track of how it’s been implemented. So the quality team will do that, and they will ask providers to report on their implementation of the guidance that affects them.

PCT senior commissioning manager

How well we use kind of research from other sources is probably more variable I think, and it’s part of everybody’s jobs, like H or S or whatever, as, you know, as the strategy managers, to keep abreast of what’s happening. And of course it’s part of professional clinicians’ jobs and service managers’ jobs to do the same, and that might involve subscribing to stuff, or, which might be more like specific alerts perhaps rather than magazines . . . So S will see stuff that I never see, and about her areas of interest. And of course the same with the GPs now, because again as clinicians and particularly sort of clinical leaders, it’s part of what they, they need to do.

PCT senior commissioning manager

Interestingly, although respondents often mentioned a lack of time and resource to read or compile primary research evidence, we also observed that some relevant in-house resources, such as literature search facilities and data analysts, were at times underutilised. Furthermore, it appeared that the actions constituting the commissioning process were not clearly prescribed, with many commissioning managers making independent decisions about how to use their time, suggesting that the lack of time for engagement with research (and other evidence) may reflect the perceived greater importance of other activities. However, there was also evidence that yearly cycles of activity and tight deadlines (a more general constraint on commissioning work) could prevent commissioning managers from feeling that they had time to regularly compile and review research (and other) evidence.

Also, it is important to note that we found no sign of any structures or processes to guide evidence use or ensure standards around the access, appraisal, synthesis or application of evidence of different types within the commissioning cycle. Thus, although it was clear that the PCTs had explicit governance arrangements for approving commissioning decisions and resource allocation, often involving structured business case templates and committee review, these did not include any explicit checklists on what types of evidence should have been drawn on or how they should be appraised or synthesised. Our observation of pieces of commissioning work further confirmed the lack of guidance to individual commissioners in terms of what evidence should be garnered and used in their work, and the consequent idiosyncrasy in how tasks were accomplished in practice.

Some themes from the national key informant interviews were importantly elaborated, or even refuted, by the case study work. First, although some key informants suggested that evidence skills are not valued in commissioners, we tended to find a more nuanced picture in our PCTs. Thus, although it was true to say that the evidence skills of health-care commissioning managers were very mixed and that this was not generally seen as a core skill, each of the three organisations had established working structures that aimed to ensure that evidence skills fed into the commissioning process effectively, although it was unclear how well these worked in practice:

It feels more like a push than a pull to me, at the moment, in terms of what I’m delivering [as a data analyst], but I’m Mr Ad Hoc in a way, a lot of what I do is kind of spur of the moment, somebody asks for something and I deliver that information, rather than be strategic or planned approaches.

PCT information officer

The data-analytical skills of both public health intelligence and performance management teams seemed to be particularly valued and drawn on extensively. Clearly, it should be recognised that the commissioning process demands a very wide range of skills and competencies and these are unlikely to be present in any one individual. So, for example, we found public health staff in lead commissioning roles who were skilled evidence users but felt ill-equipped to effectively manage contract negotiations, as well as strategic managers who had the opposite skill mix. Similarly, the case study work tended to suggest a more positive picture than the key informant interviews with regard to the range of evidence sources that are recognised by commissioning organisations.

Notwithstanding the fact that the actual impact on commissioning decisions was still felt to be limited, we found that in two of the sites there was organisational support for drawing in varied types of evidence, particularly patient experiences, which links closely with the national quality agenda. It was also noticeable, for example, in relation to the JSNA that work to enhance the inclusion of qualitative, experience-rich evidence had recently been started in two of the sites. Nevertheless, it was clear that understandings of what counts as evidence remain variable and fluid within organisations, and that there was little by way of guidance or standards on how different evidence sources should be weighted or integrated.

A further important theme highlighted by some of the national key informants was the selective use of evidence to support decisions already made rather than to inform such decisions. Respondent reports and observational work confirmed instances of this type of evidence use across two of the three sites. For example, the selective use of evidence to construct internal business cases was widely recognised. However, it is important to note that this type of evidence use was recognised as not being ideal and seemed to conflict with the mental models of how evidence should be used for many involved in commissioning:

I’m personally not convinced that we are that systematic with the assessment of evidence and evidence base, I would suspect that, there’s a, there’s occasional, if not more than occasional, use of selective evidence to make the argument.

PCT senior commissioning manager

[Reflecting on a piece of needs assessment work] It was nice to do, you know, and to really understand the issue, because it did feel a bit like oh, well actually we’re going to look and see what the issue is and then work out what to do about it, which felt like the right way around, you know, sometimes things go round in different ways, don’t they?

PCT public health practitioner/commissioner

A final important finding from the case study work was the generally poor management of knowledge and evidence within these commissioning organisations. We found that a lot of knowledge was personal rather than collective, and that evidence generated internally could have a narrow audience and a short life (although this was not always the case). This seemed to reflect both practical obstacles, including limited physical and computer-based storage space, and a tendency towards silo working, a lack of reflective culture and an absence of processes to prompt documentation and evidence compilation. It was interesting to note that the NHS restructuring prompted the production of various legacy documents that detailed work programmes in ways that were rare to find previously.

Organisational structures and influences on ethnicity evidence use

Clearly, many of the factors operating at organisational level to shape general evidence use are also relevant when the focus is on ethnic diversity and inequality. In addition, however, the key informant interviews and case study work suggest some factors that have particular significance for this area of work, as well as some additional themes that may be specific to evidence use on ethnicity. Table 7 highlights how these factors were reflected across the three case study sites.

TABLE 7

TABLE 7

Strategic level: organisational structures and influences on evidence use on ethnic diversity and inequality

The case studies confirmed that currently all three organisations were operating with an inadequate demographic and health profile of their local populations by ethnicity. There were, however, signs that work was under way in all three sites with an explicit focus on improving data, apparently prompted by the legal duty in the Equality Act 201099 to identify and publish equality information and objectives. It remains to be seen whether these initiatives will lead to greater collection and utilisation of such data within commissioning, as past progress on ethnic monitoring in primary care in one site had not yet resulted in such a shift, highlighting the need for complementary work to increase the demand for evidence on ethnicity:

The reason why we’ve got no decent monitoring is because either people don’t think it’s relevant, it’s not important, or they’re afraid to ask, nor do the commissioners require it I expect, they say that they do . . . [but] there’s no consequences, no one cares, I think that, in the same way that if you don’t put your accounts in, year on year, then you should have the auditors crawling on your back, I believe that you should not only have your ethnicity data and your basic demographics in, but you should also be able to chart and show and demonstrate progress.

Third-sector manager

There was wide variation across and within the three PCTs in terms of the extent to which practitioners and clinicians were regularly engaged in commissioning work, with some examples of strong, ongoing engagement. However, in all three sites we observed and heard reports of missed opportunities to draw valuable insights from practitioners and clinicians into the commissioning process relating to the needs of minority ethnic people. Although this is clearly a wider issue, there was evidence to suggest that a failure to use such provider insight may be a particular problem when there is a large social distance between commissioners and service users. The third-sector and community organisation representatives who we spoke to felt that they struggled to find a way to inform the commissioning processes and sometimes described instances in which evidence that they had presented to commissioners had been contested or was not valued. At the same time, some commissioners expressed doubts about the representativeness of particular community groups or worried that community forums were dominated by a narrow range of people, and could therefore be dissuaded from drawing on evidence from such sources.

It seems that such organisations may often be in the difficult position of having to play the multiple roles of advocate, knowledge bearer and potential provider of services to minority ethnic communities, with consequent concerns about vested interests being raised by commissioners.

More generally, there were concerns that structures did not effectively connect PCT staff working at community level with more senior decision-makers, so that their knowledge remains outside the commissioning arena. The Innov8 (described in Chapter 5) work taking place in one case study site was an explicit attempt to address this shortcoming in the field of mental health.

The case studies also tended to confirm the failure of PCT structures and processes to ensure good representation of minority ethnic people within consultation and engagement initiatives, despite a few notable exceptions. There was little evidence of the PCTs firmly accepting their responsibility for ensuring such representation, with no significant investment in this area (as has been the case in some places, reported by the key informants) and commissioning staff at times openly contesting whether it was their job to ensure such input. It was also apparent that in two of the three sites there was poor coherence at community level, with no active partnership for health among the ‘BME’ third sector, meaning that there was a weak and inconsistent challenge to commissioners to achieve better representation and address unmet needs in BME communities. Although some individual members of commissioning staff were working to improve the situation, they did not appear to receive organisational support for this.

As noted above, the case studies revealed few structures and processes to support commissioners’ access to, and use of, research evidence in general, with a heavy reliance on national policy and guidance documents. Although clearly this will mean that a large amount of potentially relevant evidence is overlooked across the board, this lack of connection to primary research may be particularly problematic for work on ethnic diversity and inequality as national guidance often does not include detail on this area and the evidence base remains new and rapidly evolving. We found little sign that use of national resources such as NHS Evidence & Ethnicity (recently discontinued) or the NHS Northwest Health Equality Library Portal (HELP) (see www.help.northwest.nhs.uk/; accessed January 2013) were promoted within the organisations, although some individuals did take their own initiative.

A further important theme highlighted by the case studies was that E&D work has not, to date, generally been expected to be evidence driven. Individuals with an E&D remit, who might raise pertinent questions regarding minority ethnic access to and experiences of services, commonly did not have strong evidence skills themselves and were not necessarily able to draw these in from other parts of the organisation. It seems possible that this situation will change in those areas where the Equality Delivery System is taken seriously (as described further in Chapter 6).

A further area confirmed by the case study work was the lack of detail included in service specifications, or contracts, regarding how services should be configured and delivered to ensure that the needs of patients and users are adequately met regardless of ethnicity. We found that there was no organisational expectation of such detail and that documents tended to include only very general statements about making services accessible to all groups of people and ensuring absence of discrimination. This tendency to limit detail in service specifications was not peculiar to ethnicity and seemed to relate to concerns about the amount of work involved to draw up detailed specifications; the danger of restricting the commissioners’ room for manoeuvre if the service was required to respond to new issues; and the complexity of monitoring contracts against a large number of requirements. Documentary review of several service specifications was carried out and, although some did specify generally that services should be ‘appropriate and meet the needs of the diverse local population’, these factors were not described in any detail nor included as measurable outcomes or performance targets.

As also noted by some of the key informants, there was a lack of clarity at the organisational level around commissioner and provider responsibilities to find service solutions and ensure effective implementation. Despite variation in the extent to which individual commissioners worked actively to support the improved delivery of services to minority ethnic people (as described further in Chapter 5), there was evidence of uncertainty about the commissioning role in questioning the performance of large provider trusts in this area, particularly when this related to behaviours and competency of staff. These factors clearly relate fundamentally to how the content and process of commissioning work is understood and operationalised within different organisations. Again, although this is a general issue, the implications of contested roles in relation to finding effective service models may be particularly important for our focus on ethnic inequalities, for which there are few tried and tested approaches and an absence of national standards or guidance.

A final important theme related to the tendency for decisions-makers to demand a higher standard of evidence when the focus was on minority ethnic health needs, again something that was noted by the national key informants. Although this was in part related to the wider organisational cultures and structures that marginalised attention to ethnic inequality, we discuss this more in Chapter 5 as its significance in blocking action also seemed to relate closely to the agency of individuals.

Copyright © Queen’s Printer and Controller of HMSO 2013. This work was produced by Salway et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK259514

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