What sort of evidence do Trust Boards and CCGs listen to? The Single Interest Pressure Group and levels of evidence. Do Commissioners and Trusts have policies to cope with them? Case studies are not valid evidence.

SIPGs or Single Interest Pressure Groups: Do Commissioners and Trusts have policies to cope with them?

Single Interest politics is not the way a democracy should run. :Like case studies, they do not present not valid evidence. For valid and reliable numbers there need to be studies that can be copied, repeated and turn out the same results.. Peer pressure can lead to poor thinking even in CCGs. Confounding factors and perverse incentives (PIs) need to be teased out and overt before decisions are reached. PIs are “drivers within a system that work against the overall intention of the system.”

In an overtly “rationed” health care system it is only rational to exclude high cost treatments of dubious or short term benefit. If rationing is not overt, then the poorer the country the bigger are the distortion effect of SIPG demands which happens to get heard and influence spending. SIPGs are a denial of democracy.

What sort of evidence do Trust Boards and CCGs listen to? When I was on my local Trust LHB I asked this question at the beginning of my appointment. The reason that I asked was because the board was asked to listen to a short presentation from a SIPG at several meetings and there seemed to be no process or system to refer to, either before  (who, why?), or after (what, when?) such a presentation. I got no answer. When I left the Trust board there was still no such process or system.

Members of Clinical Commissioning Groups (CCGs) have been heard to say that they like to hear “case studies” before they make decisions. If real evidence is to be used, then NHSreality disputes that such persons are fit to be on a CCG. Case studies and anecdotes share the same “power” and are statistically insignificant.

All CCG and board members should have an appreciation of statistics, and their interpretation. They should also be aware of the different “levels of evidence” (Patient Plus):

  • A variety of grading systems for evidence and recommendations is currently in use. The system used is usually defined at the beginning of any guidelines publication.
  • The hierarchy of evidence and the recommendation gradings relate to the strength of the literature and not necessarily to clinical importance.[9]

Grading of evidence

  • Ia: systematic review or meta-analysis of RCTs.
  • Ib: at least one RCT.
  • IIa: at least one well-designed controlled study without randomisation.
  • IIb: at least one well-designed quasi-experimental study, such as a cohort study.
  • III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case-control studies and case series.
  • IV: expert committee reports, opinions and/or clinical experience of respected authorities.

Grading of recommendations

  • A: based on hierarchy I evidence.
  • B: based on hierarchy II evidence or extrapolated from hierarchy I evidence.
  • C: based on hierarchy II evidence or extrapolated from hierarchy I or II evidence.
  • D: directly based on hierarchy IV evidence or extrapolated from hierarchy I, II or III evidence

A simpler system of ABC is recommended by the US Government Agency for Health Care Policy and Research (AHCPR):

  • A: requires at least one RCT as part of the body of evidence.
  • B: requires availability of well-conducted clinical studies but no RCTs in the body of evidence.
  • C: requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

Guideline Recommendation and Evidence Grading (GREG)

In an attempt to improve the way recommendations and evidence statements are graded, the GREG grading system has been used:

  • Evidence grade:
    • I (High): the described effect is plausible, precisely quantified and not vulnerable to bias.
    • II (Intermediate): the described effect is plausible but is not quantified precisely or may be vulnerable to bias.
    • III (Low): concerns about plausibility or vulnerability to bias severely limit the value of the effect being described and quantified.
  • Recommendation grade:
    • A (Recommendation): there is robust evidence to recommend a pattern of care.
    • B (Provisional recommendation): on balance of evidence, a pattern of care is recommended with caution.
    • C (Consensus opinion): evidence being inadequate, a pattern of care is recommended by consensus.


This entry was posted in A Personal View, Commissioning, Perverse Incentives, Professionals, Rationing, Trust Board Directors on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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