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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 3The wider context: findings from national key informant interviews


This chapter draws on the 19 national-level key informant interviews, detailed in Table 1. These interviews were expected to generate information in response to research questions 1 and 3, detailed below, with a particular focus on the wider policy context and organisational factors that direct and shape commissioning work, and the place of evidence use within this arena.



National key informants

Research question 1: how does a focus on ethnic diversity and inequality shape the knowledge mobilisation and utilisation process within the health services commissioning context?

  • What factors prompt managers to seek out research (and other types of evidence) relating to ethnic diversity and inequality?
  • To what extent is the accessing and application of information relating to ethnic diversity and inequality part and parcel of broader evidence-gathering exercises for commissioning or rather a distinct exercise?
  • What characteristics of research evidence relating to ethnic diversity and inequality influence how it is received by managers?

Research question 3: how can individual, team and organisational competencies effectively be enhanced to support critical use of research evidence for the commissioning of services that better meet the needs of our multiethnic population?

  • What factors in the wider societal and broader NHS context shape the routine, critical use of research evidence in commissioning for multiethnic populations?
  • How does research (and other) evidence relating to ethnic diversity and inequality currently find its way into the commissioning process – through which actors and which routes?
  • Who are the key actors and what are the key organisational settings and processes that present barriers against enhanced mobilisation and utilisation of evidence?

The bulk of this chapter is devoted to describing these wider contextual issues. However, in practice, many of the key informants also offered important insights into micro-level factors operating at the level of individuals and teams. We have noted these where relevant, although most were explored in greater detail through the case study work, which is presented in Chapters 4 and 5.

As noted in Chapter 2, our data collection did not focus narrowly on patterns of ethnicity evidence use but also solicited a wider range of information on commissioning structures and processes, and evidence use more generally. Key informant interviews were therefore loosely structured to allow respondents the opportunity to shape their responses and highlight the issues that they felt to be important. In particular, we did not offer any precise definition of ‘evidence’ but encouraged respondents to think broadly about the varied types of evidence (or knowledge) that play a part in commissioning work, with formal research evidence being just one aspect of this bigger picture.

Exploring generic commissioning drivers, structures and processes was important as these were likely to fundamentally shape the demand for evidence of different types as well as the access to, and use of, evidence within commissioning work. Further, an understanding of the more generic landscape was felt to be important in ensuring that any claims made for factors operating in relation to our focus on ethnic diversity and inequality were informed by an understanding of processes that shape and constrain evidence use in commissioning work more generally.

For this reason the findings in the present chapter are organised into three main sections: general findings relating to (1) evidence-informed commissioning and (2) ethnic diversity and inequality within English health-care policy and practice, followed by findings relating more specifically to (3) use of evidence on ethnic diversity and inequality in commissioning. Although research evidence did feature in respondents’ narratives, they also discussed a wide range of other types of evidence, reflecting the fact that these may often feature more prominently within commissioning work.

Respondents have been identified by their current broad role and sector but most had varied backgrounds giving them experience of different aspects of commissioning and evidence mobilisation processes. People in director-level roles have been identified as ‘senior managers’. More specific titles have been avoided to preserve anonymity.

Evidence-informed health-care commissioning: rhetoric and reality

What is health-care commissioning? What kinds of models are used?

The key informants varied in how closely they had been involved in commissioning work, yet all had sufficient exposure to commissioning organisations to provide useful commentary on the general features of commissioning structures and processes.

All respondents recognised commissioning as a complex set of activities, the intention of which is to shape health services to better meet population health needs:

I think, my sense is that commissioning actually covers a lot of different sorts of activities, but broadly speaking it’s the process of understanding the health needs of a population, and planning and procuring services to meet those needs. But within that, you know, there’s a lot of different sorts of functions, and different kind of patterns about how that might be carried out.

Third-sector manager and analyst

However, the consensus was that there was wide variation in the ways in which PCTs have been organised and commissioning work has been achieved in practice. Some respondents drew distinctions between PCT and local authority commissioning, but most felt that there was also important variability in approach and quality within each of these commissioning arenas.

To an extent, such variability might be considered to reflect an appropriately responsive system, in that no single model of commissioning might be suitable for all circumstances. Nevertheless, there was also a sense in the respondents’ reports that there remains a lack of clarity in terms of what ‘good commissioning’ might look like and significant contestation of roles and responsibilities within the commissioning arena. Moreover, although all respondents felt that commissioning should be an important lever for health-care redesign and improvement, most also expressed the feeling that the transformational potential of commissioning remains largely unrealised. For this reason it is important to examine the scope of variation described, with three distinct inter-related areas of variation evident.

First, respondents felt that there was important variation in the extent to which people in commissioning roles saw their job as one of transforming services to better meet needs as opposed to ensuring robust control of contracts and budgets (the so-called ‘transactional’ elements). Our respondents indicated that they felt that the former aspects were very important but were, in practice, not always emphasised:

I guess a broader role of bringing in, you know, not just the evidence, but . . . more widely [thinking] about the problems and how they would be resolved and what other bits of the system would be part of that. I think that’s what many of us would think was meant by ‘commissioning’. But then, you know, meeting people who have that ‘commissioner’ in their title, they, you know, often had a more contractual focus with the organisations, in terms of, you know, what would be delivered, and how it would be performance monitored.

Public health observatory senior manager and analyst

Second, respondents suggested that there was substantial variation in people’s understandings regarding the extent to which commissioning should be carried out exclusively by people formally identified as ‘commissioners’ rather than a diverse range of stakeholders being actively engaged (in assessing need, reviewing provision, identifying viable solutions and monitoring this process of ongoing improvement). Whether and how such diverse stakeholder working might be organised and managed in commissioning practices appears to vary widely:

It’s kind of, yeah, I suppose sort of two different views on what it is. Is the commissioning what commissioners do, in terms of tighter contractual type . . . of development, or is it, is it a broad role of a lot of people in the system?

Public health observatory senior manager and analyst

Third, respondents highlighted variation in opinions and practice regarding the extent to which commissioners and commissioning can, and should, contribute to the identification and implementation of service solutions, rather than focusing solely on the clear specification of outcomes required (so-called ‘black box’ commissioning). In other words, there appeared to be a lack of clarity in terms of where the boundaries of responsibility for different elements of service improvement might lie:

From talking to the voluntary sector in particular, they say their commissioners are not really particularly interested in that [service specification], it’s very much more about, well, how many people have you seen, is that in line with what we’ve asked you to see, and things. But actually understanding a bit more about what intervention is used and why it’s effective or not effective.

Third-sector senior manager

Commissioning is a fantastically blunt tool . . . quite a lot of commissioning is about bean counting . . . counting patients in, patients out.

Public health observatory senior manager

Notwithstanding this apparent variation in orientations to commissioning, respondents identified a range of more systemic factors that they felt made transformational commissioning difficult. Many respondents drew attention to the centrality of the relationships between PCTs and NHS provider trusts. They highlighted the greater political power of the provider organisations and the limited room for manoeuvre that this afforded commissioners whose budgets were felt to be (predominantly) tied up in large historical contracts and who often have no alternative source of provision:

I think the second big issue, which is a pertinent one, is really the momentum of the historical contracts . . . you know, a lot of what the commissioners are doing is almost working at the margins. Where you’ve got extra resources you can have a discussion about how they’re best deployed. Obviously most of the resources are in a basic set of core contracts to provide a hospital with an accident and emergency department, medicine and surgery and that kind of thing.

Public health observatory senior manager and analyst

I don’t think it works in a consistent, sustainable way anyway, because we’ve been pretty much, I think, commissioning the same [services] and we’ve very rarely decommissioned anything. So as commissioners – mental health services is a classic – it feels like we need to tear up the whole thing and start again. So . . . I think the whole thing isn’t working. The way that we describe it theoretically in the NHS . . . In theory that’s the way to do it, but in reality I don’t think it works anyway.

Strategic health authority senior manager

Some respondents drew attention to the inherent tensions and complexities in the system and particularly the lack of clarity around how a market-inspired model of commissioning should function in practice:

But [commissioning’s] origins have come out, you know, have come out of the purchaser–provider split, and I’m not sure how well thought through, in a sense there’s quite a lot of theoretical work about how providers ought to behave in a [market] You know, the model is an essentially market model, which is that you split the purchaser and the provider apart, and we kind of, there’s a model for how providers ought to behave, you know, faced with these incentives, but there seems to be much less work on what the incentive, you know, what should be driving commissioners or purchasers to do a good job.

Third-sector manager and analyst

What drives commissioning?

Across the board respondents felt that the major driver for commissioning action was currently a financial one. Some respondents noted that, although it was often considered to be taboo to explicitly discuss health-care rationing (with concepts of efficiency and value for money being seen as more palatable), a drive to cut costs did in fact underpin most work. Respondents noted that the prompt for PCT transformational work often resulted from national comparative data that indicated spend was high in a particular area, or national directives concerning ways of improving value and cutting costs:

You know, so in that sense the, often the driver of the commissioning is financial rather than more to do with the clinical and quality type issues. So that these things become a sort of add on to the contract, but you know, maybe almost irrelevant if somebody’s saying well you know, you need 5% efficiency savings this year.

Public health observatory senior manager and analyst

Several respondents also referred to the quality agenda and NHS Outcomes Frameworks93 as being influential in directing commissioning energy and resources.

That said, the key informants also felt that those national agendas that focused on other issues could be very influential in directing the work of PCTs. This is because PCTs were felt to be ‘obedient’ in this regard, such that national priorities would even take precedence over local needs and divert commissioning resource away from other work:

I mean if there is a national agenda on a certain something, vascular health checks programme is a clear example. No one had heard of that until three years ago . . . suddenly that became a key priority nationally and the PCTs were tasked to deliver that, and they then develop different models of delivering that within the PCT, and it’s suddenly happening.


Respondents acknowledged that the health inequalities agenda was prominent in health policy rhetoric, but felt that in practice this was not a major driver and remained a marginal concern within the commissioning work of most PCTs, where it was often equated with the work of the public health team within the PCT. One respondent used a football analogy, referring to public health commissioning as ‘minor league’ compared with the bulk of the PCT’s ‘premiership commissioning’ for primary and secondary care. Respondents noted the predominant focus of PCT activity on patients and service users – whether through a concern to curb demand or raise quality standards – and felt that this meant that the wider population, and inequalities in service access, are rarely a focus of attention for health-care commissioners.

Evidence use in commissioning

Most of the key informants expressed the opinion that evidence should be central to the commissioning process and that a wide range of evidence sources must be drawn on and synthesised to inform strong commissioning work, with formal research evidence being just part of this picture.

However, there was general agreement that, in practice, systematic and effective use of evidence was not routine. Respondents were aware of good examples in which commissioners had adopted a systematic and rigorous approach to mobilising and synthesising diverse sources of evidence to inform decisions, but noted that this was usually in response to a clear policy or local driver (e.g. an individual funding request) and that external assistance is often sought in undertaking this kind of more detailed work:

PCTs have got a record of delving into the evidence when they need to, certainly for making decisions about, you know, whether drugs are cost-effective or not, you know, there can be quite systematic reviews [of the evidence] that PCTs do.

Third-sector manager and analyst

Respondents felt that the variability in evidence use was in part explained by limited commissioning resource. They felt that commissioning work was often rushed and linked to annual cycles and budgets, and there was simply a lack of capacity to look carefully at each issue or draw on diverse evidence sources. This was felt to be contributing to a tendency to maintain existing patterns of purchasing rather than seeking to redesign services.

However, in addition to resource constraints, respondents highlighted the ways in which commissioners’ approaches to finding and using evidence are shaped by other factors. Respondents tended to agree that certain types of information and evidence are more prominent and more routinely used within commissioning than others, in particular those types of evidence that relate to costs, which appeared to reflect the prominence of financial drivers:

PCTs have large information departments and they link to their local public health observatories and they make use of data sets like the compendium . . . All the programme budgeting stuff, that looks at outcomes in relation to spend.

Third-sector manager and analyst

Some respondents expressed concern that there was sometimes very selective use of evidence on the part of commissioners, with evidence being used to provide support for decisions that have already been taken, rather than being used to inform understanding of an issue and thereafter guide an appropriate response. They also highlighted the political nature of commissioning and the way in which decisions can often be influenced by vocal interest groups – as one respondent put it, ‘whoever shouts loudest’ – rather than by a balanced review of the available evidence:

Evidence is not, you know, politically neutral, it either emphasises something, or you know, sort of backs up, you know, something that somebody believes anyway, or contradicts it, and therefore it’s, you know, it’s evaluated in that particular way. And one of the issues I think when you’re looking at things critically is that . . . sometimes you’re just looking for evidence to back up your point of view, as opposed to looking at everything out there, and I think that’s a big sort of issue as well around sort of commissioning.

Third-sector senior manager

In relation to research evidence, respondents generally felt that commissioners were most heavily reliant on national guidance and other forms of synthesised evidence, and that many commissioners did not access primary research evidence. Indeed, respondents referred to the process by which research evidence informed commissioning as both ‘ad hoc’ and ‘precarious’:

[It depends upon] people with a bee in their bonnet . . . in terms of the evidence bubbling up through other routes, that’s kind of a bit of a precarious thing.

Public health observatory senior manager and analyst

In some cases, respondents felt that this reflected the fact that commissioners were working on areas about which they knew very little. Research evidence was more likely to be drawn on either when particular researchers had built up a strong relationship with commissioners and were conducting research locally or when clinicians were engaged in the commissioning process, as these clinicians were considered more likely to be well versed in the evidence base relating to their area of expertise.

Further, several respondents felt that there was a need for commissioners, and the commissioning process, to expand and extend what counts as evidence and to recognise the value of different types of information and insight. In particular, these respondents were concerned that insight from patient experience and public consultation might potentially be very useful in improving services yet was not commonly drawn on in a systematic fashion to influence the commissioning process:

I mean there was a process about what is counted as evidence, and then what is published, you know, sort of a key thing. What is valued as evidence as well, and of course the value of evidence that is not random controlled trials.

Third-sector senior manager

Some respondents pointed to the lack of standards around good evidence use in commissioning. Several also felt that there was substantial variation in the skills and interests of different commissioning actors – variation that affected how evidence was brought into the commissioning process. Appraisal and synthesis skills were highlighted as particularly important for commissioners given the wide range of relevant information and the challenge of translating national guidance into local-level action. Yet these skills (appraisal and synthesis) were felt to be lacking and were often not recognised as a core requirement for commissioners. Some respondents also noted that, when commissioning teams are constituted to ensure representation of organisations or professional groups rather than skill sets, expertise in evidence-related skills can end up lacking. On this, respondent narratives suggested that commissioning organisations and teams rarely have assigned ongoing roles and responsibilities to identify or generate relevant evidence and channel it into the appropriate part of the commissioning process. Instead, evidence generation and evidence mobilisation appear to occur more as discrete, allocated pieces of work. For instance, a focused needs assessment may be commissioned from an external research company or a literature review may be undertaken by a specialty registrar in public health based at a PCT for part of their training:

They usually ask us [third sector/GP researcher] for the evidence . . . That’s an area that definitely commissioners do not have much expertise in, that I’m aware of anyway. There may be some PCTs who have evidence synthesis officers or something, but that’s something that we have spoken to our commissioners about [needing in future structures].


What we find is that commissioners are not very good at using evidence and understanding the different kinds of evidence that there are.

Third-sector senior manager

Some respondents also expressed concern that PCTs tended to use consultants for various elements of the evidence-gathering and synthesising tasks rather than developing these skills and subsequent in-depth understanding in-house. Consultants appear to be used regularly for a range of evidence-related tasks, including needs assessments, community consultation and insight work, research evidence syntheses, projection work and economic modelling:

I’ve always been sceptical where people sort of contract out a needs assessment, because it seems to me that has to be done by the commissioner, because they have to internalise that knowledge in order to be able to, over the next few years, commission those services better. They need to know everybody that’s involved on the provider side. They need to know the sort of broader population understanding.

Public health observatory senior manager and analyst

Respondents also highlighted the fragmented nature of commissioning work, so that evidence skills, even if available within organisations, often sit within silos and are not necessarily brought to bear where needed:

The bits of the process don’t always link together . . . the people who are perhaps particularly interested in evidence about best treatments, and you know, data about numbers and projections and things, are often within public health, are often not integral to the people who call themselves commissioners . . . so there may be good knowledge about evidence, but it’s not playing in at the right place at the right time to change contracts.

Public health observatory senior manager and analyst

Innovation through commissioning

Commissioning was not generally considered to be an important source of innovation by our respondents. Commissioners were often characterised as risk averse:

So if I give you the commissioners’ perspective, you know, at the end of the day we’re accountable for public money. I have to visibly show how I’ve spent it. New things are very uncomfortable.


Commissioners were also felt to be distant from the realities of service delivery, making them unlikely to identify opportunities for innovation:

Examples of innovation are there, but these are despite rather than because of the system.

Third-sector senior manager

These observations linked closely to respondents’ opinions that ‘strong commissioning’ – commissioning that actually transforms services to better meet needs – has to involve a wide range of stakeholders. Several respondents highlighted the importance of having clinicians and other front-line practitioners closely engaged with the commissioning process. These respondents felt that this was essential to ensure adequate understanding of the realities of delivering the service and that health-care practitioners with this understanding were therefore more often a source of innovation. They also noted that, even when the impetus for change comes from commissioners, providers have to be committed to the innovation for it to happen:

There was an end of life care [project] . . . it worked with the palliative care commissioners and also with heart failure nurses, so it was a carers’ organisation . . . but they worked really well with commissioners, and also they had really self-critical evaluation about what difference they made . . . and it influenced the strategic plan around palliative care, because the commissioner was involved from the beginning, in fact they were joint bidders.

Third-sector senior manager

Some respondents also felt that innovation is more likely when the commissioning process draws in the public and potential users of the service in a meaningful way:

So the local authority absolutely threw a fit right at the beginning, saying, you know, ‘what do you mean you’re going to put a mental health unit in the xxx?’ And then slowly as we’ve got them on board, then we’ve got the local authority on board . . . And it only got off the ground, and that design only worked because it was the public who asked for it.

GP/ex-senior commissioner

A couple of respondents identified a further characteristic of commissioning work that they felt often undermined the potential for innovation, namely the failure to carefully evaluate service redesigns. These respondents felt that commissioners tended to focus on ‘bottom-line’ outcomes rather than generating learning through unpacking the processes and understanding what did and did not work as anticipated.

Nevertheless, some respondents did feel that PCT commissioning was improving, and that progress was being made, at least in some areas, towards more responsive and impactful commissioning that took population health needs as the focal point:

In terms of structural thinking I think PCTs were a really good invention; they were bringing public health down to a local level, using that to inform commissioning process, really having responsibility for linking in with primary care providers. I think there was a lot of potential there . . . innovative thinking . . . I do see that that would have come in time.

Third-sector senior manager

Ethnic diversity and inequality in English health-care policy and practice


An important theme within the key informant interviews was that attention to ethnic diversity and inequality remains a marginal concern within English national health-care policy:

I always say that people don’t get discriminated any more, the equality and inclusion agenda gets the discrimination . . . it’s the area itself that gets the discrimination, that gets less resources, that gets the less importance . . . Which of [the] agendas do you think is going to be keeping people awake at night time? It will not be the inclusion agenda. It will be QIPP and commissioning and providing. So there is a hierarchy in the importance of areas within the NHS.

Strategic health authority senior manager

There was some disagreement between respondents in terms of whether there had been any progress during the period of the Labour government (1997–2010), with some feeling that real progress had been made within the DH and central policy during this time and others suggesting that there had never been genuine commitment from the top to make this a core policy driver. Nonetheless, respondents agreed that other priorities and agendas tended to take precedence and they drew attention to the ways in which equalities work could be presented as conflicting with, rather than aligned to, other priorities:

They don’t have to be, but in this modern world where senior decision makers don’t understand the equality inclusion agenda, and often some of them don’t believe in that agenda, then it becomes conflicting, yes, it’s one or the other.

Strategic health authority senior manager

Several respondents drew attention to the apparent synergies between the quality agenda and equalities issues but noted that in practice there was very little connection at national or trust level. One respondent had spent time reviewing quality accounts across a large number of trusts and found that they had been prepared with little or no reference to equalities issues. Others explained the need to convince people working on quality issues of the relevance of taking an equalities focus:

If you look at quality one of the big features in and around that is around patient experience. How can you get patient experience right if you’re not disaggregating and getting the patient experience, whether qualitative or quantitative, of all the different groups that are using those services? I think for those people leading on quality, until you start talking about all of that, they don’t really get it at all, they just really see it as ‘oh E&D, that doesn’t really apply to us’. But actually you can’t really achieve quality for everybody unless you achieve equality in that process.

Strategic health authority senior manager

[QIPP] has a financial component in it, but to be interrogating that in terms of equality as opposed to just quality, no. It was not part of the package.

Third-sector senior manager

Several respondents also highlighted the way in which the national health inequalities agenda has lacked adequate reference to ethnicity, opting to understand inequalities primarily in terms of differences between geographical areas and socioeconomic groups:

Every review of health inequalities has excluded ethnicity. The previous one said they couldn’t do it because the data wasn’t good enough. Now the data’s good enough . . . [but] until there is some sort of ‘must do’, ‘have to do’, I think we are not going to [do it].

Public health observatory senior manager

I said repeatedly that it was completely unhelpful that the previous policy agenda had health inequalities here and the equality agenda here [indicates with hands wide apart]. So the equality agenda was formulated in terms of the law and fairness and justice and non-discrimination and so on, whereas the health inequalities agenda was coming from a different perspective.

Third-sector manager and analyst

The only exception to this picture of marginalisation was in relation to mental health work, in which several respondents highlighted significant national policy drivers to understand and tackle ethnic inequalities. However, even in relation to mental health, some respondents felt that progress had been disappointing and that gains on the ground had not been matched by system-wide changes to mainstream ethnic inequality within commissioning work.

Respondents felt that this general lack of strong direction from national policy-makers was often reflected at the local level in the behaviour of PCTs. They felt that in most PCTs there was no sign that attention to ethnic diversity and inequality was embedded within the main commissioning processes. Some respondents felt that attention to ethnic diversity and inequality had largely been confined to an internal human resources issue, or had taken on a very narrow legal compliance focus within PCTs, rather than being a fundamental part of knowing and responding to the health needs of the local population. One respondent even referred to a ‘get out of jail free card’ to signify the way in which PCTs showcased a one-off project focusing on ethnic inequality issues, in lieu of being able to demonstrate a consistent and embedded approach to this axis of inequality.

I think locally it still remains a very Cinderella issue I think for many groups, for many areas . . . I think overall it’s probably still not that high on people’s radar, is it?

Third-sector manager and analyst

I think because we’re still moving from what is a very white Anglo-centric approach to health care to recognising difference as part of our community, rather than something that if we’ve got time and leisure we’ll deal with.

Third-sector senior manager

PCTs seem to have interpreted a lot of this, a lot of them have tried to meet the legal duties, you know . . . you know, the action was taken to write equalities schemes, and comply with the law, and . . . there was almost a sort of disconnect, you know, inequalities, the racial and ethnic inequalities really related to writing a race equality scheme, at the time. But actually, if you really, you know, a PCT that was doing something about this would have its public health people kind of, you know, embedded and immersed in that whole agenda, and not its human resources, you know, legal people, who were writing this document.

Third-sector manager and analyst

Importantly, several respondents highlighted the fact that there had never been any performance management focused on ethnic (or other) equalities-related outcomes. Respondents noted that this meant that the work had not been a ‘must do’ and that, in the target-driven culture of the NHS, this absence of either a carrot or a stick had served to keep the issue at the margins:

There is a prior problem here, which goes back to the regulation side. If this isn’t monitored, as you know, a national priority, then most people are not going to worry about it are they?

Third-sector manager and analyst

We measure everything else within the NHS. We’ve got targets; over the top most of the time. But around this agenda, we’ve never really had measurement.

Strategic health authority senior manager

Some respondents noted significant variation in the extent to which ethnic inequality is taken seriously in commissioning organisations. However, respondents felt that this gulf had not changed much over time and that there could well be slippage backwards in the future, with organisations becoming less attentive to this issue:

I think you’ve got a big continuum haven’t you from the people who are engaged, switched on and fairly active in this area, right through to the other end, to people who say ‘what?’ And that’s always been there, because that’s one of the things I’m struck by, is over the last ten years, it’s always been . . . one or two proactive [places] like that, and there’s all these others where there is less happening. Why has that whole curve not shifted over time? It doesn’t seem to have.

Third-sector senior manager

Ignorance, ambivalence and obstruction at senior level

Some key informants suggested that the marginalisation of the ethnic equality agenda within the DH and the NHS could be explained in part by ambivalence and complacency on the part of senior leaders and in part by their need to prioritise action within a host of competing agendas. As one respondent put it, there are ‘many distractions’. Thus, some respondents drew attention to senior policy-makers who they felt were not convinced that important ethnic inequalities exist, or who they felt believed that such issues are already understood and dealt with without the need for specific measures:

So I think there’s something around people not seeing it, not seeing it as important.


Decision makers who feel that we already have a fair society, that we already have an equal world, that we already have a very civilised society, so therefore all this inclusion and equality resources that we’re putting in is political correctness gone mad.

Strategic health authority senior manager

In London, in many places, my sense is that there is a belief that – of course we’re commissioning for BME needs . . . we have been doing that for years, so what’s your problem?!

Third-sector senior manager

Other respondents felt that the default position within the DH and much of the NHS is simply to overlook the relevance of this dimension:

Nobody in the Department of Health thinks about it. I think the information centre is all in different bits so they don’t necessarily join up on this. I wish I could think that there was a conspiracy theory – I just think it’s default.

Third-sector manager and analyst

I go to meetings so many times and I’m the only black face there. And I know this issue of equality is happening but nobody raises it. They just try to ignore it. And so you do raise it, people like me have to raise it, because if nobody else will, I always will. But it shouldn’t have to be that way.

Strategic health authority senior manager

However, some respondents also drew attention to more active forms of obstruction and undermining that they felt were linked to the protection of professional boundaries, vested interests and the contestation of minority ethnic entitlement and representation:

It [race equality] is divorced because people have got a monopoly on health inequalities. Those people who are working in it don’t want the inclusion and equality agenda to be anywhere near it because they’re protecting their own jobs, their own little power houses. That’s what it is, the reality of it from my experience, that’s what I think . . . Otherwise actually inclusion and health inequalities fit very nicely together. It’s a natural fit.

Strategic health authority senior manager

The other dimension where the local authority’s involved . . . is [where] you start to get into a political dimension about who ‘our people’ are, and you know, where we should be focusing resources on, on local people, you know and that, and that, there’s a risk that . . . local people can actually be, you know, stereotyping that as, someone who was born and bred in the area . . . and all these other groups are kind of not necessarily local.

Public health observatory senior manager

Most respondents also identified a lack of comfort in raising issues related to race and ethnicity that served to silence discussion and further marginalise the agenda. Respondents noted that people could often be fearful and perceive the topic as politically sensitive and complex, with the result that they would try to avoid it:

I think it’s uncomfortable, because, and part of it’s around what we view as politically correct and not politically correct . . . otherwise we’d be talking about it quite openly. There is an element of, it’s a bit of a taboo subject.

GP/ex-senior commissioner

There was certainly a degree of concern about either stereotyping or, you know, sort of representing communities in particular difficult ways . . . and so it’s one thing to be aware of the background, it’s another thing to say certain things up front and out loud.

Local authority consultant

They had a race equality review as part of being a Race for Health PCT, but nobody would talk about race equality in the room, we were with their board, all the senior people . . . The local authority and the PCT are absolutely – it’s the same in XX – absolutely terrified that there’ll be a backlash if they focus on BME communities.

Strategic health authority senior manager

Notwithstanding possible variation in the underlying attitudes and perspectives that might characterise particular actors’ avoidance of or obstruction towards the ethnic equality agenda, key informants felt that a lack of senior leadership and an absence of concern regarding ethnic inequalities were common across PCTs: ‘Very rarely do we get key players at a senior level pushing this agenda’ (strategic health authority senior manager).

Lack of infrastructure and resources

Respondents felt that the ethnic equality agenda lacked adequate infrastructure and resources at national and local levels. They pointed out that central initiatives that could be helpful, for instance the NHS Equality and Diversity Council, were not effectively connected to what happens on the ground within PCTs.

At the level of local PCTs, respondents noted the varied location and number of staff within each organisation who had an E&D role and responsibility. This was felt to usually be a small resource that was isolated from core commissioning work. Some commented that it was rare to have senior posts devoted to this agenda and contrasted the limited investment in this area of work with the investment in agendas with greater legitimacy. Moreover, respondents felt that there was often a heavy dependence on just one or two people within organisations, often individuals of minority ethnic identity themselves, who were tasked with pursuing this agenda and acting as spokespersons for very diverse communities. Respondents referred to such staff ‘battling’ alone and becoming frustrated and exhausted:

One person appointed on equality to make that happen is very demanding. It’s draining. It won’t happen . . . We would never expect QIPP to be done on a part-time or voluntary basis.

Strategic health authority senior manager

Elsewhere, some respondents noted the reliance on unpaid community representatives to provide relevant input to commissioning processes. Meanwhile, respondents also felt that PCT structures and processes rarely linked E&D activities effectively into other elements of the organisation and did not hold staff members elsewhere to account on this agenda. For example, equality strategies and equality impact assessments, although useful in theory, were identified as often being tick-box exercises that were not linked to action:

How are the priorities, as set out in the Single Equality Scheme, linked back to the strategic plans of that organisation? Most of the time they sit out in a vacuum and most of the time the priorities set out in the Single Equality Scheme don’t even feature anywhere near any of the strategic business plans at all.

Strategic health authority senior manager

Lack of confidence and competence among commissioners

A further important theme highlighted by key informants related to the lack of confidence and competence to address ethnic diversity and inequality among commissioning staff. Respondents felt that in some PCTs the lack of diversity within the workforce and the lack of connection to issues of inequality contributed to low levels of both confidence and understanding. They were also concerned that PCTs had been quick to cut engagement and equality posts in ongoing restructuring, thereby removing people who might have otherwise contributed a sustained understanding of minority ethnic needs and experiences.

As before, respondents noted that external consultants were often being called in from outside, so that expertise and resources tend not to be mainstreamed or embedded. And again, there was felt to be a tendency for PCTs to assume that members of staff from ethnic minority backgrounds would provide the necessary source of insight and would champion this agenda. Yet this went hand in hand with substantial reluctance on the part of some BME professionals to take on the mantle of this role (in part as a result of the marginalisation and exhaustion experienced by others, as described earlier). Elsewhere, some key informants reported a general unwillingness, both in themselves or amongst colleagues, to consistently raise the issue of ethnic inequality when other people did not, primarily because they were concerned that they might be perceived to be conflating personal and professional issues. Respondents also noted that, although public health might be considered the natural home for inequalities work within PCTs, this did not necessarily translate into a consistent and careful consideration of ethnic inequality amongst public health staff, this instead being highly dependent on individual confidence, expertise and interests.

Respondents also felt that commissioners could often hold unsophisticated understandings around ethnicity and often had a tendency to stereotype rather than recognise intragroup heterogeneity and changes in group needs, aspirations and experiences over time. These respondents worried that commissioners essentially tended to blame minority ethnic people themselves for poor access or poor experiences rather than considering potential limitations of the services on offer. As such, these commissioners were felt to equate responding to minority ethnic needs with the need for additional resources and/or special services:

So some people [commissioners] are a bit wary of going to certain groupings . . . [I’m thinking of] a very well educated executive who wouldn’t be willing to go to any of these, any of these meetings [with the Somali community] . . . I suppose internally within the system we’ve stereotyped what groups ask for, so what’s happened is actually without going out they’ve just assumed it’s going to be an angry mob.

GP/ex-senior commissioner

At the same time, however, respondents acknowledged the ways in which understanding and responding to ethnic inequalities can be complex and challenging. In this, they pointed to the need for greater support and direction at national level to equip commissioners to respond appropriately to these complexities and challenges.

Nonetheless, respondents’ narratives suggest that the lack of a wider supportive context means that there is no particular impetus for commissioning managers or their teams to recognise or address their low levels of understanding, confidence and competence, and no clear penalties for failing to do so: ‘People don’t know what they don’t know and so avoid it altogether’ (DH senior consultant).

Competing ways of making the case

Reading across and between the key informant interviews revealed the varied and conflicting ways in which the need for attention to ethnic diversity and inequality within health-care policy and practice is framed by different actors.

Interestingly, most respondents felt that focusing on legal duties had not been productive, serving instead simply to reinforce a compliance or ‘tick-box’ mentality rather than encouraging people to take ownership and enthusiastic action. Moreover, although some argued that social justice and discrimination provides the only legitimate frame of reference, others found this focus to be unhelpful and off-putting, and some even felt that framing the issue always in terms of inequality was potentially stigmatising and disempowering for minority groups: ‘The moment you raise the race agenda, people back off because they’re scared’ (third-sector manager and analyst).

Some respondents were particularly concerned about focusing on racial discrimination within the health service, which they felt had been overplayed and had served to alienate key actors who needed to be persuaded to work towards the same objectives rather than defending their (in)action. Others also argued that a predominant focus on racism, particularly within the mental health service arena, had diverted attention away from understanding a wider range of factors that might also contribute to higher levels of ill health amongst minority ethnic populations, including wider social disadvantage.

Elsewhere, some of the key informants talked about people strategically aligning the agenda with the ‘flavour of the month’, and worried that this made equalities work vulnerable to short-termism and threatened longer-term gains:

Equality and fairness on its own is an important area, and those leaders who lose that, lose a very fundamental thing. You can’t pick and choose equality and fairness into different areas. Human rights and fairness is a given for everybody. It’s the cornerstone for any business . . . It should be because it’s the right and the fundamental thing to do . . . It doesn’t have to be linked with QIPP. It needs to stand on its own as a priority. Let QIPP come to human rights and equality and inclusion area.

Strategic health authority senior manager

However, others argued the case that equality was genuinely an integral part of quality and efficiency issues and wanted to see a greater effort to position it more closely with these agendas regardless of their recent emergence as topical drivers of commissioning practice. This was felt to be part and parcel of mainstreaming inequalities work within, and aligning it to, core processes: ‘[We need to have] equalities embedded in the boring stuff that people feel they had to do, because that’s the way that people accept it as part of the institutional framework’ (NHS manager).

However, some examples of respondents’ aspirations for such alignment used language that did not necessarily serve to focus attention on ethnic health inequalities:

We aligned it [diversity and equality] with world-class commissioning . . . if you look at the competencies they apply to any commissioner really . . . So competency 5 was about knowing your population and the health needs of your population. Competency 3 was about partnership and how you’re engaging at a local level and all those.

Strategic health authority senior manager

Perhaps unsurprisingly, some respondents also pointed to the need to ensure that arguments for paying greater attention to minority ethnic needs were framed in terms of cost savings and/or efficiency:

What happens is things are pulled, because financially our situation has changed, and so therefore the priority is to take things off the table, and it becomes a bit of a soft target.

GP/ex-senior commissioner

If the condition is leading to increased cost, admission rates, referral rates, then we won’t have to give them any evidence, they’ve got that evidence and those are key priority areas for them, to reduce admission rates, reduce referral rates.


Several of our key informants were themselves aware of the potential conflicts between, for instance, arguments based on potential cost savings and those focused on issues of social justice, and felt that progress could be (and had been) undermined by advocates pulling in different directions. Some argued instead for the need to use a variety of arguments – as one respondent said, ‘to pump on all sides’ (third-sector senior manager) – to increase action on this agenda.

Enhancing health care for minority ethnic people: a role for commissioning?

Most of the key informants we spoke to considered commissioning to have a key role to play in improving health care for minority ethnic people and tackling ethnic inequalities:

Our philosophy and approach round the whole equalities agenda, because it really does need to sit in the heart of commissioning, and that’s half your battle over once you get the commissioning end of it right.

Strategic health authority senior manager

Although recognising that there are issues with providers around race equality, the real lever for change lies within commissioning.

Third-sector senior manager

Two aspects of understanding and addressing ethnic diversity and inequality highlighted by respondents seem particularly tied to the commissioning role. First is the importance of understanding the health needs of the whole population, including the needs of those people who are not already accessing services. Second is the need to address shortfalls in the ability of current provider organisations to deliver the types of services that are required to meet diverse needs, that is, the need to ‘develop the market’.

Although respondents saw commissioning as a real lever for improvement, they also recognised that significant progress still needs to be made, and that commissioners have hitherto rarely pushed the agenda. Some key informants felt that provider organisations, particularly committed health-care practitioners or third-sector organisations, were most often the current source of innovation around meeting minority needs: ‘This comes back to a committed clinician identifying a need and doing something about it’ (third-sector senior manager).

Although respondents identified some PCTs that had achieved a more embedded approach to considering and addressing ethnic diversity and inequality, they generally felt that their responses had been piecemeal – being characterised by passionate individuals and short-lived projects, or being prompted by some kind of serious problem rather than being proactive and sustained:

The whole of this needs to feature right the way through that [commissioning cycle], so right from identifying needs. So you identify a particular need, you then find the right providers to commission that and then build into the requirements what it is that you want them to specifically do. Whereas, at the moment, we don’t . . . We kind of commission whatever service and just commission it for the whole population but not really set any requirements for different parts of our population that might need to access that service or experience that service in a particular way.

Strategic health authority senior manager

Use of evidence on ethnic diversity and inequality in commissioning: current patterns and influences

Patterns of evidence use

Most respondents argued that evidence use should be a big part of effective commissioning for multiethnic populations and that a wide range of complementary evidence sources were useful at different stages of the commissioning cycle:

There’s information at all sorts of levels. There is the demographic stuff, just knowing who’s living in your patch . . . the epidemiological information . . . the health observatory work and other sources, what that means in potential need for services . . . But then there also needs to be the opportunity to engage with representatives of local communities . . . where commissioners actually listen to what is being said about what is needed.

Third-sector senior manager

However, perhaps reflecting the wider marginalisation of the ethnic equality agenda, and the patchy use of evidence more generally described above, all respondents felt that in practice there was often very limited use of evidence on ethnic diversity and inequality within commissioning work.

In terms of understanding population health needs and identifying gaps in provision, most respondents emphasised the central importance of good ethnic monitoring data, particularly in primary care, as this was felt to offer a population-level ethnic profile.

Some respondents also drew attention to the potential of JSNAs to widen the focus of commissioning beyond those who already engage with services to those with unmet need. Nonetheless, these respondents raised concerns about the current lack of adequate depth of JSNAs in relation to minority ethnic communities and their weak connection to either strategy or action: ‘What we found from that evaluation [looking across a region] was that JSNAs themselves don’t disaggregate [population groups]’ (strategic health authority senior manager).

As before, respondents were often aware of examples of good practice, for instance when special pieces of needs assessment work had been commissioned by PCTs, but felt that these were usually the exception rather than the rule:

What they did was set up their own engine around patient profiling and they supported their GP practices. I think they’ve got well over 50% now of GP practices or more who are doing the patient profiling, and they’re not just doing it by ethnicity.

Third-sector manager and analyst

In relation to identifying solutions and procuring services, key informants thought that it was rare for service specifications to include detail on how services should address ethnic diversity or tackle inequalities. One respondent felt that, even when commissioners were aware of the need for service providers to address ethnic inequalities, it would be unusual for commissioners to compile evidence around potential service responses or to use such information to inform the service specification, with one respondent noting that this would be considered ‘a nicety not a necessity’ (GP respondent with extensive past commissioning experience).

Respondents felt that practitioner experience and insight could be important both in flagging up problems and in identifying viable routes of intervention to improve services for minority ethnic people. Key informants gave examples of clinicians raising issues and pushing for appropriate responses, and also of some PCTs that had facilitated inputs into the commissioning process from community development workers, thereby gleaning important insights about unmet need and poor service experiences. But once again, respondents often felt that these aspects generally needed further strengthening.

Finally, in terms of monitoring performance and prompting further improvement through the analysis of service processes and outcomes, respondents gave few examples of contracts, key performance indicators (KPIs) or performance review mechanisms being used to generate information on service performance in relation to different ethnic groups. Several participants regarded evidence of patient experience, whether generated through qualitative or quantitative data sources, as an important potential source of information. Nonetheless, they felt that this evidence was often not drawn on by commissioners, and was rarely disaggregated by ethnic group. Indeed, even when respondents described initiatives to commission new services that met the needs of an ethnically diverse patient population, it was rare for these to also include provision for monitoring against ethnicity-specific outcomes:

So, the thing about ethnic minorities, making sure there’s stuff in there [in contracts] about equality, doing equity audits, using interpreters and so on. But then I think it’s worth doing, because you know, most professionals will take on-board those things, but on the other hand there’s almost never the capacity to actually monitor whether that’s really happened in practice . . . so monitoring is very unsophisticated.

Public health observatory senior manager

Gaps in data and evidence

The key informants identified a range of issues relating to the quality and quantity of available evidence on ethnic diversity and inequality that contributed to the low levels of usage described above.

First, most respondents highlighted the absence of a detailed consideration of minority ethnic needs within many influential policy documents, such as National Service Frameworks (see Second, many respondents highlighted the persistent poor quality of ethnic monitoring/patient profiling data within service settings, and particularly within primary care. Third, many respondents felt that there was still little evidence on how services should be shaped to address ethnic diversity and inequalities. One respondent described this situation as ‘scandalous’, arguing that the academic public health community had failed to provide an adequate steer for commissioners on ‘what works’ to reduce minority ethnic disadvantage (as well as other health inequalities). Several respondents noted that, in the absence of alternatives, commissioners predominantly drew on national syntheses of evidence, such as those produced by NICE, and that these include very little detail on how to shape services for minority ethnic populations. Fourth, respondents pointed to the lack of all-important information on the cost-effectiveness of interventions/service modifications, something they argued was essential in the current climate of cost-cutting to build appropriate business cases for selective dis- and reinvestment.

Notwithstanding the gaps in the evidence base, key informants also felt that commissioners could often be guilty of overlooking potentially important sources of evidence or assuming that there was a lack of evidence when this was patently not the case. For instance, some respondents pointed out that ethnic monitoring data is often more complete than might be imagined and that there are strategies that can be used to work around incomplete data and produce useful information. Yet they felt that commissioners frequently did not request such data from provider organisations. Indeed, the general failure on the part of commissioners to ask such questions of the data that were available was highlighted by several respondents:

What we found was the commissioners were really, really weak on setting these requirements in terms of this cycle for the providers. When we went to talk to the providers, the providers were saying actually we’ve got loads of data and evidence that we collect but the commissioners never asked for it around ethnicity.

Strategic health authority senior manager

Some respondents also noted the many missed opportunities for generating evidence through the careful piloting of innovative interventions. They felt that too many initiatives aimed at addressing minority ethnic disadvantage were short-lived and remained unevaluated, so that lessons were neither learnt within the organisation nor shared more widely. Some respondents also felt that commissioners were too reluctant to seek out and learn from interventions developed and tested elsewhere; in the words of one respondent, there is a culture of ‘if it’s not made here then it doesn’t fit’ (third-sector senior manager). Similarly, they felt that too few commissioners drew on national data and research evidence to inform their local picture:

I think most of the time people don’t know how to use the national published research at all, and I think if you look at commissioning . . . I think there’s a lot of work to be done with the commissioning teams . . . I think there’s a major issue about their capability and competence to be able to use [evidence].

Strategic health authority senior manager

Many of the key informants felt that commissioners were not generally good at drawing on the expertise of, and insight from, third-sector organisations or service users and members of the public from minority ethnic communities, to fill gaps in their understanding of need or identify viable solutions:

There are many sources and we need to look beyond the kind of NHS sources as well, because there are lots of third sector organisations, both regionally and nationally or locally that might be working with some of the groups that have far better information about their communities on certain health issues, but we’re not really gathering that. Even when they’re coming to us as the advocates or the activists through their local interest networks or whatever and giving us that information, is it making the journey into commissioning for example? I think there are serious question marks about that.

Strategic health authority senior manager

Well in central XX we have no XX service, and there’s no patient there coming forward, because they’re not as coordinated, they can’t speak the language, they can’t articulate very well what their needs are, and so therefore they can’t really, they have very little advocacy, and so you have that disparity which plays out in the system too . . . you’ve already silenced the voices if that makes sense, of a lot of ethnic minority groups, because they don’t understand the system, and they have very few people who represent them in the system.

GP/ex-senior commissioner

In addition to missed opportunities to draw in relevant evidence, some key informants bemoaned the lack of a push from commissioners to improve processes of data collection, analysis and reporting. In particular, respondents noted the persistent lack of commissioner pressure for better ethnic monitoring: ‘I think the London Strategic Health Authority actually set targets for their PCTs and GPs to roll out ethnicity recording. But . . . it’s always been patchy’ (third-sector manager and analyst).

Some felt that continued scepticism about the value of ethnic monitoring among some practitioners and commissioners tended to hamper progress. In contrast, others felt that it reflected a basic lack of will power to prioritise this area, or even suggested an intentional resistance to collecting and reporting these data:

The lack of data is actually kind of a useful shield for people to do nothing with as well, so you know, the fact that we haven’t put ethnicity high up in any of this is because there hasn’t been data, it’s not in anyone’s interest to have data, because then, then you might see something you have to fix.

Third-sector manager and analyst

Conceptual and practical challenges

In addition to their more general observations on the quality and quantity of evidence relating to ethnic diversity and inequality, the key informant interviews highlighted a number of important challenges that are encountered in generating and mobilising evidence on ethnic diversity and inequality.

First, respondents noted a range of challenges relating to describing patterns of health and health care by ethnicity, including high levels of population turnover and the need for regular updating; a lack of enumeration of smaller ethnic groups rendering them invisible in quantitative data; and heterogeneity within ethnic categories and the need for more detailed breakdowns (such as by age, language competency, migration status or religion).

Second, some key informants identified a range of complexities relating to commissioners’ broader understanding of poor access, poor experiences and poor outcomes for minority ethnic people; and particularly the importance of unpacking the underlying causes to identify potential interventions that might be prescribed by commissioners. For instance, key informants highlighted the complex relationships between minority ethnic identity and low socioeconomic status, and between minority ethnic identity and migrant status:

All the things that come with low socioeconomic status, are a factor in it, but . . . there’s various aspects to culture and language and other things, you know, entangled with this . . . you know, you’ll need to think about the two things at the same time, but conceptually it’s quite tricky . . . but I think this is a real problem . . . because I think unless that gets, you know, straightened out it is very difficult for people to know what they think they’re doing, and understand ‘what is this problem we’re trying to solve here?’

Third-sector manager and analyst

Third, the interviews highlighted challenges in relation to identifying effective responses to unmet need and inequalities. Respondents noted a lack of guidance on how findings on the effectiveness of interventions should be translated across different contexts, and the need to weigh up the pros and cons of specialist service responses compared with the pros and cons of efforts to accommodate diverse needs within mainstream services. Some respondents also felt that it was difficult for commissioners to establish feasible approaches to monitoring service outcomes by ethnicity and thereby determine the degree of success of service modifications.

More generally, several respondents alerted us to the need for work that more clearly identified standards and expectations around commissioning services to meet diverse needs and address inequalities. They felt that pockets of innovation and progress often existed in isolation, and that more sharing of lessons learned was needed to establish common understandings and encourage more consistent attention to these: ‘You know, the idea of what good practice would look like, I think that is a question worth bottoming out’ (third-sector manager and analyst).

Mobilising evidence for improved services

There were somewhat mixed views among the key informants in relation to how important the generation and application of evidence might be to the goal of improving service access, experiences and outcomes for minority ethnic people.

Some respondents recognised the increasingly strong discourse around evidence-based policy-making and felt that a lack of data and evidence on ethnic diversity and inequality presented a major obstacle to action. As mentioned earlier, respondents were concerned about the absence of detail on minority ethnic health needs, particularly in JSNAs, which they felt undermined efforts to make progress in this area; as one respondent said, ‘you’ve lost at first base’ (strategic health authority senior manager). Likewise, respondents felt that the limited evidence on effective interventional strategies to address ethnic inequalities was a major impediment to action in the current climate:

I think part of it [lack of attention] is due to lack of information . . . a lot of the data on access to services and so on just isn’t there by ethnicity.

Third-sector manager and analyst

Because that’s the other thing that then inhibits people, is saying, ‘OK, so you’ve told me what the problem is, let’s do something about it’, ‘oh well let’s do an evidence based response to this’, and of course you’re back in the woods again, because you don’t know necessarily what’s going to work.

Third-sector manager and analyst

These respondents also emphasised the importance of rigorous evidence use, arguing that poor analysis leads to inappropriate responses. Some even accused other stakeholders of ‘muddled thinking’ and questioned the extent to which programmes of work aimed at tackling ethnic inequalities – such as Delivering Race Equality94 and Pacesetters95 – had been sufficiently ‘evidence based’:

You do the epidemiology and guide your prioritisation and your actions on that basis, rather than just treating people as a homogenous group of black or Asian people, do you know what I mean? I think sometimes the race agenda didn’t do itself any favours by taking that kind of victim role all the time . . . So I think if you really want to tackle the problem you need to do your diagnostic properly and scientifically. I think that’s really what I’m saying. We need to bring science to it.

Third-sector manager and analyst

In contrast, other respondents, although acknowledging the contribution of data and research evidence, questioned whether weaknesses in this area were really the most significant obstacles to progress towards improved services:

It just feels like some of it, it’s not rocket science to find out what’s happening with some of the black and Asian communities [in town X] . . . I could have told them that at the age of ten, some of it. But yet, nothing significantly – we’ve been doing things at the edges, tinkering at the edges . . . the Asian population is huge [in town X] . . . Yet in terms of commissioning and targeted interventions of that community, it’s still not . . . you know. It’s the same in Y; any community you look at.

Strategic health authority senior manager

Selective research, selective thinking. For example, if they want to progress on, say, diabetes within the Asian community, or infant mortality amongst Pakistani women, there’s enough information out there that tells us exactly where the issues are, where the concerns and the problems are. What stops people doing that? . . . There isn’t that passion to make things happen for that particular group.

Strategic health authority senior manager

Linked to this awareness of other, more systemic factors blocking action towards improved services, several respondents talked about the need to connect decision-makers to the issues and felt that evidence needed to play a role in this, acting in an influential rather than a purely instrumental way. A combination of personal stories alongside hard facts was thought to be particularly powerful here, with one respondent describing a ‘pincer movement’ to influence key decision-makers, bringing together national statistics showing the scale of an issue with an authentic personal narrative, so that the ‘light bulb goes on’ (third-sector senior manager).

Respondents also emphasised the need for ongoing engagement and persistence, as audiences are often not already primed and progress is likely to be slow:

Just evidence to show that, how badly people are dealing with a particular issue, that needs to be almost a starting point.

Public health observatory senior manager

I think part of the challenge really for a lot of, and especially with the new GP commissioners, is getting them to understand that there might be a problem here.

Third-sector manager and analyst

Respondents also talked about the importance of the credibility of the evidence and its bearer, and the significance of using peer networks – particularly among clinicians – to effectively mobilise evidence. They felt that different audiences were comfortable with, and valued, different types of evidence (particularly whether this was qualitative or quantitative evidence) but that many commissioners recognised the need for instrumental, ‘how to’ evidence most readily:

GP/academic: I think they need statistics, in terms of if there is a problem in access, in referrals, you know, in high referrals, low referrals, mortality, I think you need to have evidence, you need, only then will someone start looking at it, if you don’t have any evidence they will say, ‘Well what, there doesn’t seem to be a problem’.

Interviewer: And particularly the quantitative evidence?

GP/academic: Yes, so much so.

Commissioners want some information, but mostly solutions with a business case.

NHS manager

Perhaps of particular significance in this area, respondents expressed concern that evidence brought to commissioning relating to minority ethnic health needs and potential solutions is often subjected to higher quality standards than that required for other issues: ‘The proof that is required for commissioning mainstream services is of a far lower level than the proof that is required for commissioning specialist services’ (third-sector senior manager).

Although respondents recognised that the current financial climate meant that any proposal would be likely to be challenged, they felt that there were two key additional factors that meant there was usually closer scrutiny of ethnicity-related evidence. First, responses to ethnic inequalities are often constructed as new and additional to, rather than as improving the quality of, existing services. Second, commissioners are usually distant from these communities, lack understanding of their needs and are fearful of taking risks. One respondent noted that these factors together tended to raise significant obstacles to action on inequalities with ‘people waiting for the evidence base for years’ (GP).

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: NBK259518


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