ABSTRACT
Busy health-care professionals have a duty to apply the evidence base to practice and decision-making. Health-care knowledge and library specialists have the skills to provide efficient and effective evidence searches. To identify the advantages and cost benefits associated with knowledge and library specialists undertaking evidence searches on behalf of health-care professionals, evidence from a literature review was combined with impact case studies of evidence searches in NHS Knowledge and Library Services, identifying time savings and cost benefits. The cost-effectiveness ratio for knowledge specialists delivering evidence searching services was identified as 1:3.85 with the current net benefit to the NHS in England estimated at £37 million (42 million U.S. dollars). A range of additional benefits are also generated through using knowledge and library specialists. Greater investment in these specialists would ensure accelerated access to better quality evidence and maximum benefit across health-care systems.
Background
Evidence-based practice is essential in modern health care. The NHS Constitution recognizes the need to use research evidence to improve health care (Citation1). In line with statutory requirements, the Care Quality Commissions (CQC) assess how well health-care providers are assessing needs and delivering evidence-based treatment (Citation2). The Health and Care Act 2022 requires Integrated Care Boards to facilitate and promote the use of evidence obtained from research in the health service.
In addition to informing clinical decisions, evidence is required to inform many other areas of health-care practice including management decisions, research, pathways and guidance development, education and learning and legal considerations. Yet the time available for health-care professionals to devote to searching for evidence is limited and they can often lack confidence and skills to perform high-quality effective searches.
NHS knowledge and library specialists are a key part of the solution to this dilemma. Effective evidence searching is one of the key skills of this profession and they undertake this work to a high standard, efficiently and effectively, saving time for the organizations they serve. In response to this, Health Education England’s Policy for NHS Library and Knowledge Services states:
The NHS workforce should be able to freely access library and knowledge services so that they can use the right knowledge and evidence to achieve excellent healthcare and health improvement (Citation3).
Anticipating the increased need for specialist staff to deliver the evidence base for busy healthcare professionals, Health Education England made a policy recommendation advocating for improvements to the ratio of the number of qualified knowledge and library specialists per member of the overall NHS healthcare workforce (Citation4). The policy recommends an increase over time from the current ratio of one qualified knowledge and library specialist for every 1,730 healthcare staff, to a ratio of 1:1250. This would represent an increase of 38.4% in qualified knowledge and library specialists across the NHS in England.
Employers rightly seek evidence around what additional benefits their organization could gain from increasing knowledge and library specialist staff numbers. Evidence from the literature suggests that professionally staffed health libraries can offer a cost-benefit ratio of between 1:2.4 and 1:9 and lead to positive impacts on health outcomes for patients and time savings for health-care professionals and can contribute to cost savings and risk management (Citation5,Citation6).
The Value Proposition report summarizes and builds upon these research findings. The report highlights that health-care staff are short of time and that health-care knowledge and library specialists can release time for these busy staff by taking on the role of facilitating access to the crucial evidence on which clinical and management decisions are based:
The core Value Proposition is simple: the service provides healthcare professional staff with time-saving accelerated access to better quality evidence which, in turn, enables the NHS to meet its statutory obligations to utilize evidence from research, and, as importantly, for health care professionals to use their time more effectively to drive improvements against the quadruple aim (Citation7)
Over 350 case studies have been collected by Health Education England’s National Knowledge and Library Service team. These provide an important addition to the evidence base around the impact of knowledge and library specialists. Many of these case studies detail the impacts of specific instances of evidence search provision (Citation8). As evidence searching is such a key element of the service provided by NHS knowledge and library specialists, it is important to focus on this area to identify the benefits offered to the NHS.
Objectives
The aim of the study was to investigate the value of evidence searching services offered by knowledge and library specialists to NHS healthcare professionals in England. This was to be achieved by applying published research results to NHS knowledge and library services, informed by data from impact case studies.
In particular, it was intended to estimate cost benefits associated with knowledge and library specialists undertaking evidence searches on behalf of health professionals in the context of the NHS in England.
Methods
The study was part of a wider piece of work, commissioned by Health Education England and led by a health economist, to develop a value proposition for NHS knowledge and library services (Citation7).
Literature review
An international review of the literature was undertaken by Economics by Design to inform the value proposition work. This literature review confirmed the existence of significant evidence supporting the value of knowledge and library specialists within the health-care sector.
Special libraries and academic libraries were the focus of a 2020 literature review which found that around $2.40 was generated for every $1 spent on health library services (Citation9). This estimate is based on the time saved for users of the service, together with associated organizational expenses.
A hospital study in the US tested a return-on-Investment tool generated by the US Department of Veterans Affairs (Citation10). Early estimates suggested a return on investment of between 2.1:1 and 4.5:1 for the three hospital libraries in which it was trialed.
A more recent US study in medical libraries indicated a range of patient benefits resulting from the use of information supplied by library professionals (Citation11). These included positive benefits such as improved patient understanding of their condition and treatments. Negative consequences were avoided as a result of access to this information including adverse events, misdiagnosis, and patient mortality.
An earlier systematic review identified an impact on patient outcomes resulting from the range of services provided by knowledge and library professionals (Citation5)
Clinical and embedded librarian services were of particular interest to the review as there is an ambition to grow the number of these roles within NHS knowledge and library services. This model of service delivery often includes the provision of evidence searching as a significant element.
Hartfiel and colleagues examined the value of the clinical librarian model within the Critical Care unit at Wirral University Teaching Hospitals NHS Trust (Citation12). Focusing on the time saved by clinical staff using the service, the study found a benefit cost ratio of 1.5:1. When wider benefits for staff and patients were taken into account, the overall benefit cost ratio increased to 3:1.
Brettle studied the impact of clinical librarians across a wider sector of the NHS. This study noted contributions to a wide range of outcomes including choice of intervention diagnosis, quality of life, and patient involvement in decision-making. The service also leveraged cost savings and improved the management of risk through the avoidance of unnecessary tests, referrals, readmissions, and by reducing patients’ length of stay (Citation6).
Focus group with library staff
NHS knowledge and library specialists provide a complex range of service offers to their customers. Occasionally specific services have been tailored to local needs and may be found in only one or two services in England. Other services are more widespread across the country and may be considered core elements of the overall offer.
The customer base can also vary with service users drawn from a wide variety of healthcare professional groups including but not limited to clinical and managerial roles. Many services are based in hospital buildings but may serve acute, community, mental health, commissioning, and a range of other staff groups.
To assist the health economist leading this work in understanding the broad landscape of NHS knowledge and library services, a focus group was convened and acted as a reference point. Members included NHS knowledge and library service managers, knowledge, and library specialists who contribute regularly to the impact case study knowledge base, and colleagues from Health Education England’s national Knowledge and Library Service team.
The initial meeting took the form of a one-day face-to-face exploratory workshop examining the breadth of services available from NHS knowledge and library services, the range of organizations and customers served, and the complexities and commonalities present in the services. This was followed up by virtual group meetings to explore themes and issues resulting from the initial workshop, supplemented by additional telephone and e-mail exchanges to clarify specific issues.
Identification of key service areas
One feature identified in the work with the focus group is the wide range and variety of services offered by knowledge and library specialists to the NHS in England. Some of these services could be considered core, being common across the country. Other services were more discrete, having developed around local requirements and influenced by stakeholders within specific contexts.
For the purposes of developing a value proposition for NHS knowledge and library services two approaches were chosen as the focus. The first was to look at the perspective of the knowledge and library service as a whole entity, the collection of individual services and resources considered as a single offer. The second approach was to consider two individual specific service offers in more detail.
The first service offer selected for focused attention was the model of embedded knowledge specialists, also known as clinical librarians. The value of this model was of particular interest as Health Education England has identified embedded librarians as a key growth area for the workforce, and a role which has the potential to make considerable positive impact on the health-care system.
The wider perspective looking at the value of the service as a whole entity, and the focused investigation of the value of embedded librarians, can be found in the final Value Proposition. The main message of this value proposition is that
the service provides healthcare professional staff with time-saving accelerated access to better quality evidence. This enables the NHS to meet its statutory obligations to utilize evidence from research. It enables health care professionals to use their time more effectively to drive improvements against the NHS quadruple aim (Citation7).
The second area identified was the evidence searching service. Evidence searching is a term used here to refer to any search for evidence undertaken by knowledge and library specialists on behalf of health-care professionals. These searches often include the interrogation of specialist health-care bibliographic databases and other sources, the shortlisting of results using a variety of criteria, and increasingly includes the production of syntheses and summaries of the findings. Evidence searching is one of the key services which Health Education England would expect to be offered by every health knowledge and library service within the NHS, and is therefore of particular interest. It is the investigation of the value of evidence searching which forms the focus of this paper.
Review of case studies
Impact Case Studies collected from NHS-funded knowledge and library services in England were reviewed to identify commonalities and good practice. These case studies are created by NHS knowledge and library professionals using a value and impact toolkit and are peer reviewed prior to being shared more widely and used for publicity, promotion, and advocacy (Citation13). Case study authors, usually the knowledge and library specialists who have provided the service, are encouraged to use the critical incident technique to focus on specific instances of health-care professional’s use of their knowledge and library service (Citation14). The process will usually include an interview or discussion with the aim of identifying impacts resulting from the intervention with the help of health-care professionals who have used the service. As well as being used locally for marketing and promotional purposes, colleagues are invited to submit their impact case studies to Health Education England for peer review with some examples being promoted in national documentation and campaigns.
Two impact case studies, shown in , were examined from NHS Trusts identified as high performing by the Care Quality Commission (CQC) and by the NHS Library and Knowledge Services Quality Assurance Framework (Citation15). These case studies reported on the impacts of evidence searches undertaken within the two Trusts. The health economist leading the work followed up these case studies, holding in-depth interviews with knowledge and library specialists from the Trusts involved. Information relating to the critical incidents reported within the case studies was taken for further analysis. These details include the time taken to perform each of the reported searches and the pay banding of the NHS knowledge and library specialists involved. Other characteristics were also noted in order to investigate the key factors contributing to the success of the knowledge and library services within these organizations.
Figure 1. Impact case study.
Figure 2. Impact case study.
Application of research findings to the NHS environment
To ensure consistency when calculating staff costs, this study made use of the fully loaded unit costs of health and social care produced at the University of Kent (Citation16).
Two factors were used to estimate the cost benefits associated with time-accelerated access to evidence. The first factor was an estimate of the time taken for knowledge and library specialists to undertake an evidence search as compared to other health-care professionals; second was an estimate of the pay or banding difference between the library and knowledge specialist and the health-care professional for whom the search was being undertaken.
Evidence from the literature or suggested that a key factor in the time saving offer of knowledge and library specialist was the length of time it would take their service users, customers, or patrons, to undertake a task compared to the expert searcher (Citation9). Through reference to this research, and in discussion with knowledge and library professionals, it was estimated that NHS knowledge and library specialists could be expected to perform an evidence search on average 3.3 times faster than other health-care professionals.
The second efficiency associated with knowledge and library specialists undertaking this work is related to the pay band difference between their staff group and the health-care professionals requesting the searches. In the majority of cases knowledge and library specialists are situated on a pay band lower than that of the healthcare professionals requesting the search. Discussions with experts within the focus group indicated that it would be appropriate to take as a conservative estimate that knowledge and library specialists are on average one pay band lower than the health-care professionals requesting the search. Referring to the unit costs referenced above this equates to a 17% average difference in salary.
To determine an overall cost-benefit ratio for evidence searching, the two figures of 17% and 3.3 were multiplied together (1.17 × 3.3) and rounded to produce a new ratio of 1:3.85.
Results
Focused analysis of the case studies and discussion with stakeholders demonstrated the following wider benefits of using qualified knowledge and library specialists to perform the search:
Knowledge and library specialists saving the time of busy health-care professionals by locating and accessing the evidence faster and more efficiently.
Improved patient care resulting from using high-quality research in evidence summaries.
Evidence-based procurement strategies resulting in better-informed organizational spending decisions.
The estimated cost benefits were calculated by referring to NHS knowledge and library services staffing data collected from Health Education England’s annual statistical return for NHS Knowledge and Library Services. These data were supplemented with information relating to the specific evidence searches highlighted in the two impact case studies selected for analysis.
The evidence search highlighted in the first impact case study example was undertaken in NHS Trust #1. Discussion with the service manager revealed that this search was conducted by a Band 6 knowledge and library specialist and took just over 8 hours. Using the fully loaded unit cost figures, the cost of this search in staff time was estimated at £376 ($437 US) (Citation16). An uplift of 17% (precise figure 116. 791,749%) was applied to this figure in recognition that library staff would on average be one band lower in pay than the individuals who would be conducting the search themselves. This resulted in an opportunity cost of £439.14 ($510.6 US), to reflect the unit cost saving. Following the methodology of the IFLA review, a time saved multiplier of 3.3 was then applied to the unit cost of £439.14 resulting in a final economic value of time saved of £1449.15 ($1684.9 US) as shown in .
Table 1. Economic value of time saved in case study search.
The second case study example highlighted the results of an evidence search undertaken in NHS Trust #2. A Band 5 knowledge and library specialist undertook the search in NHS Trust #2 and took just over 11 hours to complete the work. The cost of this search in staff time was estimated at £396 ($460.4 US). An uplift of 17% (precise figure 116. 791,749%) was applied resulting in a figure of £462.50 ($537,8 US). Following the methodology of the IFLA review, a time saved multiplier of 3.3 was applied to this figure resulting in a final economic value of time saved of £1,526.23 ($1,526.23.9 US) as shown in .
It should be acknowledged here that many evidence searches will not require the time commitment indicated while others may require additional time to complete.
In order to expand these findings to estimate overall timesavings across the NHS in England, the annual NHS knowledge and library services statistical return figures were utilized. More than thirty-two thousand (32,463) searches were reported as being undertaken by knowledge and library specialists across the NHS in England during 2018–19.
Sample data from an NHS knowledge and library service participating in the focus group exercise suggested that the average time taken for a comprehensive evidence search was six hours, while a search requiring evidence synthesis and summaries averaged 13 hours to complete. Out of a sample of 66 searches undertaken by the same service, 37 were standard searches while 26 involved synthesis and summaries.
The weighted time spent on searching was calculated using these data in the following way:
Weighted time = (6 × 37/66) + (13 × 26/66) = 8.48 recurring.
The annual cost of a Band 6 undertaking this activity was estimated by multiplying this figure with the reported number of annual searches and by the cost of a Band 6 taken from the fully loaded unit cost figures, (8.4848 r × 32,463 × 47) resulting in a figure of £12,945,850.91 ($15,052,270.3 US) per annum.
To estimate how much longer non-specialists might take to undertake the same searches, the uplift and multiplier were applied resulting in a figure of £49,894,962.64 ($58,013,372 US).
Health Education England has made a policy recommendation advocating for improvements to the ratio of the number of qualified knowledge and library specialists per member of the overall NHS health-care workforce (Citation16). The policy recommends an increase over time from the current ratio of 1 qualified knowledge and library specialist for every 1,730 health-care staff, to a ratio of 1:1250. This would represent an increase of 38.4% in qualified knowledge and library specialists across the NHS in England.
As evidence searches form a significant element of the role of many knowledge and library specialists, it is a reasonable to propose that an increase in capacity would result in an increase in the number of evidence searches this specialist workforce is able to undertake.
The 38.4% figure was therefore applied to the current estimate of economic benefit to provide a projected estimate of additional benefit should the recommended staffing ratio to be achieved across England. This revealed a potential increased net benefit of around £14 million ($16.3 m US), taking the overall potential estimated net benefit to around £51 million ($59.3 m). It should be noted these are net figures after additional staff costs have been accounted for, .
Table 2. Potential national net benefit of knowledge and library specialist searches.
Features of high performing NHS knowledge and library services
It is important to consider the conditions under which NHS knowledge and library services can be empowered to achieve the level of benefits outlined above. The study reviewed a small number of case studies from services in Trusts which had scored well with the Care Quality Commission in terms of their use of evidence, and which had high compliance with Health Education England’s Library Quality Assurance Framework (Citation15).
Determination of those factors which were key to the success of these high-performing knowledge and library services is crucial to enabling the replication of success elsewhere. This is particularly the case where organizations wish to maximize on the economic benefits highlighted in this study. Analysis of case studies, and interviews with the knowledge and library specialists from these organizations, highlighted some key success factors for these high performing knowledge and library services.
Key considerations for those NHS organizations wishing to maximize the benefits obtained from their knowledge and library service included ensuring their service are:
Adequately resourced in line with Health Education England recommendations.
Positioned correctly from a governance and assurance and physical perspective to be strategically effective for the Trust and the wider health system and aligned with health system goals.
Empowered to support the organization to adopt best-practice guidelines from NICE and to adhere to CQC standards and requirements.
Well managed in line with HEE policies and standards.
Discussion
Evidence searching accounts for a significant proportion of the time of NHS knowledge and library specialists in England with over 32,000 searches reported by this group of staff during 2018–19.
Although the search process itself can be time-consuming for health professionals, the task of sorting through the large number of references which can result from such searches can be even more demanding. To respond to this issue, Health Education England has commissioned training and development opportunities for knowledge and library staff focusing on the synthesis and summarizing of search results. Over the past few years, many NHS knowledge and library specialists have attended this training and have begun including summarizing services as part of their knowledge and library service offer. The resulting evidence summaries provide more accessible digests for busy health-care staff, removing the need for them to read through multiple papers to identify the key points.
The benefits of this model are simple. Knowledge and library professionals are often paid far less than the clinical and managerial staff for whom they are carrying out the search activities. This brings the first level of economic benefit in terms of salary costs for the work undertaken. In addition to this there is a second consideration around efficiency. Evidence searching, and increasingly summaries and synthesis work, is the bread and butter of knowledge and library specialist roles. They are experienced in this area of work and have a network of fellow experts to consult in case of any unusual queries arising from the search process. This experience and expertise enables knowledge specialists to perform searches more quickly and more comprehensively than many other members of health-care staff, leading to further economic benefits associated with them undertaking the work.
Expansion of the embedded and clinical knowledge specialist workforce is a priority of the national Knowledge for Healthcare strategy Citation18. The provision of evidence searches at the point of need is one important element of this role. Rather than health-care staff identifying evidence requirements and approaching the knowledge and library service with an enquiry, this model sees knowledge specialists embedded within clinical and management teams, identifying evidence needs though participation in meetings, ward rounds, and other collaborative work, and proactively undertaking evidence searches and other activities to meet the needs of the team.
Evidence searching work is highly valued by the health-care professionals who benefit from it with positive feedback and a wide variety of impacts identified at local level. Although saving the time of health-care professionals is just one of many impacts resulting from this work, it is the most consistent and easily quantifiable. Therefore, while recognizing that this study is only measuring the tip of the iceberg in terms of the impacts of the work of knowledge and library specialists, it is this time saving which this study focused on.
Despite the clear benefits associated with knowledge and library services, they are not as widely used as they could be within the NHS. There may be a range of reasons for this. First, there is a challenge of visibility and awareness. Skills of knowledge and library specialists are not always recognized widely within NHS organizations by those who could benefit from them. They may be seen by some potential service users as a resource for those undertaking educational activity rather than a business-critical organizational asset.
Another challenge is one of accessibility. NHS funded knowledge and library services are often found in NHS Trusts meaning that some NHS organizations and staff may not have access to the skills of knowledge and library professionals. Where knowledge and library services exist, capacity may be limited. This can lead to knowledge specialists being reluctant to promote and market their services too widely for fear of being unable to meet demand.
This study should be viewed within this context. The study acknowledges and confirms the findings from previous research which indicate a wide range of impacts resulting from the use of knowledge and library specialists to locate evidence in health. These impacts are covered within the background section of this paper but broadly include positive impacts on health outcomes for patients, avoidance of adverse events and unnecessary procedures, and improved patient choice and quality of life.
However, the main focus of this study is on the economic benefits associated with the use of NHS knowledge and library specialists to undertake evidence searches for health-care staff. The findings agree with and build upon earlier studies which found that the services of health knowledge and library specialists can lead to cost savings, generate a return on investment, and lead to time savings for those health-care professionals availing themselves of these services (Citation6,Citation10,Citation17,).
The contribution of this study to the evidence base is the national perspective taken to measure the economic benefit of knowledge and library specialists delivering evidence searches to the NHS. Findings from international research are applied to the NHS context and a simple modeling exercise is used to illustrate the potential economic value of the services based solely on the value of time saved. The resulting analysis suggests a considerable benefit in terms of time saving for health-care professionals. This is expressed in terms of an estimated economic benefit to the NHS in England from using the skills of knowledge and library specialists to undertake evidence searches. A further potential economic benefit opportunity is highlighted which would result from recommended staff ratios between knowledge and library specialists and health-care staff being introduced across the NHS in England (Citation4).
The nature of the knowledge and library services included in the analysis is an important consideration in reflecting on the results of this study. Several high performing NHS knowledge and library services were reviewed as part of the work. These were services in Trusts which had scored well with the Care Quality Commission in terms of their use of evidence, and which had high compliance with Health Education England’s Library Quality Assurance Framework. Analysis of case studies and interviews with the knowledge and library specialists highlighted key success factors for high performing knowledge and library services.
Conclusions
This study suggests that the existing economic benefit of health-care knowledge and library specialists performing evidence searches for the NHS may be in the region of £37 ($43 m US) million per annum, with the potential to increase to £51 million ($59.3 m US) per annum if Health Education England’s staff ratio policy recommendations were introduced.
NHS organizations that do not have access to knowledge and library specialists to perform evidence searches are missing out on these considerable economic benefits. Their healthcare and management staff may be undertaking searches less efficiently and at a greater cost to the organization. In some cases, they may be commissioning evidence searches from commercial companies at considerable expense. It is the collective responsibility of Health Education England and NHS knowledge and library specialists to continue to promote the advantages of NHS knowledge specialists to these organizations and to work with them to increase access to these business-critical services for the NHS workforce.
For those NHS organizations already benefitting from NHS knowledge and library specialists, the study poses additional targets. First, there is the challenge of ensuring appropriate numbers of knowledge specialists to meet the needs of the organization; second there are the considerations around empowerment, organizational positioning, and management, highlighted by the report as essential to knowledge and library services reaching their potential to deliver on the economic benefits described.
Knowledge and library services, and organizational decision makers wishing to enhance the value of their knowledge and library specialists are able to use these guidance points to improve their local services and maximize the gift of time for health professionals.
Acknowledgements
The authors thank Imrana Ghumra, Head of Knowledge Services, University Hospitals Coventry and Warwickshire NHS Trust and Alison Horner Le Riche, Library and Knowledge Service Manager, Royal Berkshire NHS Foundation Trust for their assistance in providing information and case studies for the paper.
Disclosure statement
Clare Edwards and Dominic Gilroy are employed by Health Education England, the body with responsibility for developing NHS funded Knowledge and Library Services in England.
Economics By Design was commissioned by Health Education England to review the economic benefit of NHS Knowledge and Library Services to the healthcare system.
Additional information
Funding
References
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