Evidence-based practice is a component of values-based commissioning (VBC) but this is balanced by service user and carer experience and perspective, clinical expertise, cultural factors, management and cost considerations5.
- Evidence may be neutral but interpretation of it is not. It is subject to individual and collective value judgements which need to be made explicit to understand their influence.
- The evidence-base has to be viewed from a broad perspective:
- meta-analyses and randomised controlled trials can be valuable in assessing defined interventions delivered over relatively short periods
- problems which endure and are multiple (involving comorbidities)6may also require longitudinal descriptions and qualitative studies of interventions and services.
- Service users and carers both provide expertise-by-experience which can, and has been, systematically collected. Service user and carer perspectives can be useful in assessing acceptability, acceptability and feasibility of treatment options; they frequently coincide but occasionally conflict; both are often quite different from staff opinion. All contribute to VBC.
- Management considerations include practicalities such as whether social issues, e.g. homelessness or risk, take precedence over therapies or choices or whether there is sufficient trained and motivated staff to provide an intervention.
- Cultural factors influence not only the uptake of health care, but also its delivery and impact (e.g. Black and Minority Ethnic (BME) groups, organisational practices and care delivery).
- Cost affects the prioritisation of what can be provided: ‘Value-based commissioning’ relates to right care, reducing variability, eliminating waste, and decommissioning interventions of limited clinical value (www.rightcare.nhs.uk).