1 Aim
To clarify route for registering service evaluations within the trust, by definition, service evaluation projects should not require formal approval from a research ethics committee.
All service evaluations conducted within the trust, by either internal or external persons, must be registered.
1.1 What is service evaluation?
A service evaluation is a way to define or measure current practice within a service. The results of the service evaluation help towards producing internal recommendations for improvements that are not intended to be generalised beyond the service area. See appendix B for further information on the differences between service evaluation, research and clinical audit.
Service evaluations must be defined using the guidelines set by the Health Research Authority (HRA). For further guidance see the is my study research decision tool.
2 Scope
All staff registering research projects conducted within the trust, by either internal or external staff.
3 Link to overarching policy
This procedure is overarched by the research governance policy.
4 Procedure
All requests to register a service evaluation should be submitted with approval from the appropriate area manager to proceed with the project.
4.1 Care group responsibilities
The manager will review the evaluation proposal and place on the agenda of the appropriate care group meeting, it is anticipated that most well developed proposals will be approved, however there may equally be valid reasons not to support evaluation requests, for example, there may already be a high volume of research, audit and evaluations already taking place, the evaluation request may not be logistically supported for example, carry too many risks or not be feasible due to operational demands, workforce commitments, finances and so on.
The care group review should consider the four ethical principles below as well as the opinion of the manager, when making a decision about an evaluation approval:
- there is a benefit to existing or future patients or others that outweighs potential burdens or risks
- each patient’s right to self-determination is respected
- each patient’s privacy and confidentiality are preserved
- the activity is fairly distributed across patient groups
4.2 Registration
Please contact the research governance team as soon as possible, and before submitting the registration form. A registration guidance email will be sent, which includes a breakdown of the requirements for registration, as well as a zip folder of document templates.
The registration form, the Health Research Authority decision tool, evaluation proposal document and any other documents, should be submitted to the service evaluation email.
The research governance team will check that the project falls into the scope of service evaluation (following the Health Research Authority and NHS guidelines) and will contact the applicant if any additional information or documents are required.
Once the application is completed, they will register the project. A formal registration letter will be sent by email to the applicant, copying the approving manager.
Please retain a copy of the registration letter with the service evaluation, and quite the reference identification (ID) on all correspondence.
If the service evaluation request is from an external source, arrangements should be made for appropriate access to the trust; this will vary dependent on the proposed evaluation. The research governance team will be responsible for ensuring checks are made and issuing appropriate letters of access to individuals. Access is granted to clinical areas and confidential data on the understanding that the trust’s policies are adhered to and the trust standards are maintained and protected (see research passport, honorary collaboration contract, honorary research contract, letter of access procedure)
If a service evaluation is significantly changed, extended or withdrawn the applicant is responsible for notifying the research governance team.
Following completion, the care group holds responsibility to determine appropriate dissemination and publication. For commissioner-initiated studies, commissioners should ensure the dissemination plan is agreed via the care group from either the director of nursing or medical director.
4.3 Guidance and support
Staff planning and conducting service evaluations are strongly recommended to review the NHS Service Evaluation Toolkit thoroughly before work begins.
The NHS Service Evaluation Toolkit, includes a suite of document templates, their use is not mandatory and can be used if wanted. Copies of core document templates will be attached to the email the research governance team send when the applicant first contacts us about a service evaluation or can be sent on request.
The Grounded Research department have limited capacity to support service evaluations, and it is expected that the hosting care group will provide or arrange for oversight and guidance in the first instance.
The governance team can provide advice on the registration process and support the decision whether a project fall under the category of service evaluation.
Where advice on planning and evaluation, methodology or write up is requested the level of support available will depend on capacity on the Grounded Research department. We do not have capacity to deliver a service evaluation on behalf of a care group unless it is part of a funded project.
Requests for guidance should be directed to the governance team in the first instance by emailing rdash.service.evaluation@nhs.net.
4.4 Data protection and information governance
The care group is responsible for ensuring that service evaluations are conducted in accordance with data protection and General Data Protection Regulation (GDPR).
If personal identifiable data will be collected or used in a different way, or if data will be transferred outside the trust, a data protection impact assessment (DPIA) might be required, the person registering the service evaluation should complete the data protection impact assessment screening questions (staff access only) on the trust intranet and take advice from the information governance team if unsure about the requirements at rdash.ig.nhs.net.
The data management plan and guidance document should be referred to when documenting data flow, and a copy should be submitted with the registration form where there is data transfer. Where a data protection impact assessment is required, a copy should also be sent to the Information Governance team.
4.5 Reporting
The Grounded Research department will report service evaluation metrics to the research and innovation group, which is a sub-committee of the trust’s board of directors. Reporting is managed by the research and innovation panel.
5 Summary
All service evaluations must:
- have care group agreement
- be submitted to the research governance team for registration using appendix A
- be registered by the research governance team before the evaluation begins
- be conducted within the guidelines of the approval and according to trust policies and procedures
6 Appendices
6.1 Appendix A registration of service evaluation form (post care group approval)
Refer to appendix A: registration of service evaluation form (staff access only).
6.2 Appendix B the simple rules
By applying the simple rules below, you will get a reasonable indication of the type of data collection activity you want to embark on and whether you need to use a local policy on the introduction of new treatments and techniques.
6.2.1 Service evaluation
- Incorporates both service or practice development and service or practice evaluation.
- Service or practice development, introduces a change in service delivery or practice for which there is evidence derived from research or other health or social care settings that have already introduced and evaluated the change. New developments should always be evaluated.
- Service or practice evaluation evaluates the effectiveness or efficiency of an existing or new service or practice that is evidence based, with the intention of generating information to inform local decision-making. This type of activity is sometimes referred to as a clinical effectiveness study, baseline audit, activity analysis, organisational audit and benchmarking.
- All service review activity should comply with clinical governance requirements and follow the ethical principles.
- Service or practice development which is concerned with the introduction of new treatments or techniques must follow local policy on introduction of new treatment and techniques.
Also refer to NHS benchmarking network policy.
6.2.2 Research
- Generates new knowledge where there is no or little research evidence available and which has the potential to be generalisable or transferrable.
- All research must comply with research governance requirements.
Also refer to Research governance policy.
6.2.3 Clinical audit
- Measures existing practice against evidence-based clinical standards
- All clinical audit must comply with clinical audit governance requirements
Also refer to clinical audit policy.
This information comes from a document titled “A Guide for Clinical Audit, Research and Service Review”. A full copy of the document can be obtained at guide for clinical audit, research and service review.
Document control
- Version: 4.
- Unique reference number: 433.
- Approved by: research and innovation group.
- Date approved: 8 July 2025.
- Name of originator or author: research governance manager.
- Name of responsible individual: chief medical officer
- Date issued: 12 September 2025.
- Review date: 31 October 2025.
Page last reviewed: September 12, 2025
Next review due: September 12, 2026
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