How are CCGs managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis

Abstract

Objectives From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.

Design We carried out two telephone surveys using a sample of CCGs. We also used a qualitative case study approach and collected data using interviews and meeting observations in four sites (CCGs).

Setting/participants We conducted 57 telephone interviews and 42 face-to-face interviews with general practitioners (GPs) and CCG staff involved in primary care co-commissioning and observed 74 meetings of CCG committees responsible for primary care co-commissioning.

Results Conflicts of interest were seen as an inevitable consequence of CCGs commissioning primary care. Particular problems arose with obtaining unbiased clinical input for new incentive schemes and providing support to GP provider federations. Participants in meetings concerning primary care co-commissioning declared conflicts of interest at the outset of meetings. Different approaches were pursued regarding GPs involvement in subsequent discussions and decisions with inconsistency in the exclusion of GPs from meetings. CCG senior management felt confident that the new governance structures and policies dealt adequately with conflicts of interest, but we found these arrangements face limitations. While the revised NHSE statutory guidance on managing conflicts of interest (2016) was seen as an improvement on the original (2014), there still remained some confusion over various terms and concepts contained therein.

Conclusions Devolving responsibility for primary care co-commissioning to CCGs created a structural conflict of interest. The NHSE statutory guidance should be refined and clarified so that CCGs can properly manage conflicts of interest. Non-clinician members of committees involved in commissioning primary care require training in order to make decisions requiring clinical input in the absence of GPs.

Read the BMJ Open article >>

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Inside the mindset of NHS managers

To find out if NHS culture is changing, our research  investigated the views of managers about competition in the NHS after the enactment of the HSCA 2012 to examine the extent to which marketisation has become an internalised feature of NHS commissioning practices, and explore how far this is actually changing the NHS in any fundamental way. We found that managers remain committed to collaboration, but pockets of competitive thinking are present.

Read Pauline Allen’s blog on LSE Business Review>>

Commissioning through competition and cooperation in the English NHS under the Health and Social Care Act 2012: evidence from a qualitative study of four clinical commissioning groups

Abstract

Objective The Health and Social Care Act 2012 (‘HSCA 2012’) introduced a new, statutory, form of regulation of competition into the National Health Service (NHS), while at the same time recognising that cooperation was necessary. NHS England’s policy document, The Five Year Forward View (‘5YFV’) of 2014 placed less emphasis on competition without altering the legislation. We explored how commissioners and providers understand the complex regulatory framework, and how they behave in relation to competition and cooperation.

Design We carried out detailed case studies in four clinical commissioning groups, using interviews and documentary analysis to explore the commissioners’ and providers’ understanding and experience of competition and cooperation.

Setting/participants We conducted 42 interviews with senior managers in commissioning organisations and senior managers in NHS and independent provider organisations (acute and community services).

Results Neither commissioners nor providers fully understand the regulatory regime in respect of competition in the NHS, and have not found that the regulatory authorities have provided adequate guidance. Despite the HSCA 2012 promoting competition, commissioners chose mainly to use collaborative strategies to effect major service reconfigurations, which is endorsed as a suitable approach by providers. Nevertheless, commissioners are using competitive tendering in respect of more peripheral services in order to improve quality of care and value for money.

Conclusions Commissioners regard the use of competition and cooperation as appropriate in the NHS currently, although collaborative strategies appear more helpful in respect of large-scale changes. However, the current regulatory framework contained in the HSCA 2012, particularly since the publication of the 5YFV, is not clear. Better guidance should be issued by the regulatory authorities.

Link to the BMJ Open article>>

PRUComm Research Review 2017

This is our fifth annual review of research and provides a brief overview of our research activities. Following confirmation last year of our extension until the end of 2018 we have now agreed a programme of work with the Department. This sees a stronger shift towards exploring the impact of system changes on commissioning. The introduction of Sustainability and Transformation Plans and new metapractice organisations creates a rapidly shifting landscape for the commissioning and delivery of healthcare in England.

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Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

Abstract

Background

The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.

Methods

We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.

Results

Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.

Conclusions

Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Link to the article [BMC open access] >>

Review of the Quality and Outcomes Framework in England

The Quality and Outcomes Framework (QOF), an incentive scheme in general practice, was introduced across the UK in 2004 to link payment to delivery of primary medical care. Drivers for its introduction included the recognition that there were variations between general practices in the quality of care and the need to increase investment to improve morale and recruitment in primary care. QOF, in the early years, led to a reduction in inequalities in delivery of those aspects of care that it incentivised. Currently, there is little variation in QOF achievement between practices – most derive maximum, or near maximum income from it.

The QOF had other effects, encouraging nurse-led multidisciplinary management of chronic disease to deliver incentivised services, and better practice computerisation, so that delivery could be recorded. However, the extent to which high QOF achievement means a higher quality service in general practice is not clear. Quality in primary care is difficult to define, but it certainly encompasses more than is measured by QOF. It is now explicit NHS policy to improve other aspects of primary care – in particular, to deliver better integrated, holistic and patient-centred care and more effective primary prevention in primary care. Whether QOF can deliver these policies has been questioned, as have its role in reducing inequalities and its ability to deliver better population health.

NHS England commissioned the Centre for Health Services Studies at the University of Kent, on behalf of the Policy Research Unit in Commissioning and the Healthcare System (PRUComm), to review the evidence of effectiveness of QOF in the context of a changing policy landscape. We examined the most recent evidence that QOF influences behaviour in general practice and health outcomes, taking a broad view of primary care quality. We also considered the evidence that QOF helps sustain changes in primary care and effects of withdrawing QOF indicators using recent patterns of QOF achievement and the published literature.

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Improving GP recruitment and retention needs a long-term strategy

The state of general practice remains a key talking point in UK healthcare with continuing concerns about difficulty of recruitment, practices closing and a general feeling that general practice is in crisis. The central policy response to this situation is the General Practice Forward View published in April 2016 which was developed from the 2015 10 Point Plan produced jointly by NHS England, the Department of Health, Health Education England, BMA and the RCGP. As part of the development work for the Forward View NHS England and the Department of Health commissioned the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) to undertake an evidence synthesis on GP recruitment, retention and re-employment – although given the paucity of literature on re-employment the review focused on recruitment and retention. The review was undertaken by Professor Stephen Peckham, Director of PRUComm, and Dr Catherine Marchand of the Centre for Health Services Studies at the University of Kent.

Overall, the published evidence in relation to GP recruitment and retention is limited and focused mainly on attracting GPs to underserved rural areas. However, the literature does provide some useful insights to factors that may support the development of specific strategies for the recruitment and retention of GPs. It was also evident that there are clear overlaps between strategies for supporting increased recruitment and retention.

Key factors that are relevant to the recruitment of GPs are primarily related to providing students with appropriate opportunities for contact with and positive exposure to general practice and general practitioners. Having good role models is particularly important and early exposure in pre-clinical training may be important in influencing future medical training choices. The training environment and location of training can also play important roles in improving recruitment to areas where there are shortages of trainees. Financial factors seem less important in influencing student’s choice for general practice – particularly in the current UK context.

More attention could be paid to the fit between skills and attributes with intellectual content and demands of the specialisation – in particular portraying general practice as a stimulating and interesting specialisation. It is also clear that factors such as lifestyle (flexibility, work-life balance, quality of life), social orientation and desire for a varied scope of practice are important factors contributing to decisions about choice of specialisation. Strategies that emphasise what are seen as the most important and rewarding aspects of the GPs job – facilities, autonomy of work, diversity of cases, education and employment opportunities for physician’s spouses in the practice location – all have a positive influence on recruitment.

Interestingly many of the factors relating to retention are similar to those related to recruitment. Positive factors as viewed by students and GPs about general practice as a profession – such as patient contact, variety, continuity of care – are intrinsic to what it means for them to be a GP. Recruitment factors highlighted positive role models, engagement with practices and socialisation into general practice while retention factors are similar in terms of supporting the ability of GPs to practice being a GP.

The evidence does suggest that tackling key aspects of job stress are important but supporting the key factors of how GPs view the essential nature of general practice in terms of patient contact may be more critical together with developing new opportunities for diversity of practice through sub-specialities and broader portfolio careers. As for the new ways of working, it is likely that the inclusion of nurses, pharmacists, and even social workers might help reduce the strain of the workload and burnout symptoms of GPs. GPs leave both for reasons of job dissatisfaction – possibly reflecting a frustration or a disappointment toward the changing roles in their practice – and also to retire before 60 years old, even if not discontent. Reasons may include lack of resilience to deal with stress but also a simple view that they have undertaken sufficient lifetime service. Generally the findings of this review are consistent with the wider literature on organisational behaviour and human resource management.

Based on our analysis of the evidence, the elements that are most likely to increase and influence recruitment in general practice include:

• exposure of medical students to successful GP role models
• early exposure to general practice
• supporting intrinsic motivational factors and career determinants

Despite continuing interest in using “golden handshakes” there is little evidence that financial targeted support will increase recruitment as recent experience in some areas of England have already demonstrated.

While we found no clear evidence of the effect of investment in retainer schemes and incentives to remain in practice on retention things that will possibly influence GPs to remain in practice include:

• supporting intrinsic factors of the job
• strategies to improve job satisfaction
• reducing job stressors such as work overload, lack of support and high demand

Download PRUComm report [pdf]>>

NHSE – IPSOS/MORI report>>

Alliance contracting, prime contracting and outcome based contracting: What can the NHS learn from elsewhere? A literature review

This report is part of the research of the Policy Research Unit in Commissioning and the Health Care System (PRUComm) on new models of contracting in the NHS, commissioned by the Department of Health.

Over the past few years the need to find new ways to integrate services has become an important policy priority in the English NHS. The formation of new organisational configurations in local health economies announced in the Five Year Forward View entails separate organisations working closely together to improve the integration of local services and allow the better use of resources. One way to achieve collaboration across organisational boundaries is through the adoption of new models of contracting, such as alliance contracting, prime provider contracting and outcome based contracting. Despite their relative novelty in the English NHS, these models have a history of use in other sectors such as construction and defence, as well as in the commissioning of public services in the UK and overseas.

This report summarises the findings of a literature review of the available evidence concerning the characteristics of these new contractual models and their implementation in other sectors. The available evidence is considered in order to draw out the lessons which may be learnt to aid the implementation of these models in the English NHS.

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PRUComm Research Review August 2016

This is the fourth annual review of our research and provides a brief overview of our current research activities.

Download PRUComm research review [pdf]>>

Public Health and Obesity in England – the New Infrastructure Examined

By Anna Coleman and Stephen Peckham

Since April 2013, we have been investigating the changing public health system in England. These changes came about as a result of the Health and Social Care Act (2012) and have had profound implications for the organisation and delivery of public health. Prior to the reforms, the public health system was criticised as lacking synergy and suffering from inefficiencies due to overlapping responsibilities. Hence a key objective of government policy was to address the perceived fragmentation through a number of changes made to the structures and organisation of public health functions, chiefly by moving public health into Local Authorities (LAs) in order to:

  • increase the emphasis on public health and disease prevention;
  • create a more joined-up system with clearer leadership;
  • have a greater impact on the wider determinants of health at local level.

Examining the impact of such changes has been challenging, especially in the context of the broader changes to the health and social care system, to other government policies in areas such as education and welfare and the wider austerity environment.

Transferring public health activities into local government sought to build on the developing role of Local Authorities (LAs) in shaping local places to create healthier environments through spatial planning and local initiatives to improve health and wellbeing.  At the same time a new body, Public Health England (PHE), was created to bring national health service leadership and commissioning and further changes were implemented with the creation of NHS England (NHSE) – at ‘arm’s length’ from Government – and Clinical Commissioning Groups (CCGs) which commission healthcare services at a local level . These structural changes have had wide ranging implications for the way in which the public health function is approached, organised and delivered. Since 2013 the key responsibility for improving the health of local populations, including reducing health inequalities, rests with democratically accountable upper tier and unitary LAs – although the NHS retains some responsibilities for protecting and improving the population’s health and reducing health inequalities through all its clinical activity.

Throughout our research we utilised ‘systems thinking’ to help us to focus on inter-relationships and emphasise holistic thinking gathered from multiple perspectives. This enabled us to describe what we found to be “a chaotic, sprawling, dynamic set of practices which were often intensely political, and a set of activities that might more closely resemble a non-system”, which was still developing as our research was conducted.

Our most recent report, is based on the findings from the last 3 years and included an initial scoping review; a review of the Communities and local Government Select Committee investigation (2013) into the proposed changes; interviews with national stakeholders; case studies in 5 LA areas (including interviews, observations, collection of documentation) and two rounds of web-based surveys (of Directors of public health and elected councillors with roles in public health) in 2014 and 2015.

Our research showed that initially LA public health teams concentrated on developing the structures and processes required for effective operation (Gadsby et al 2014). We demonstrate that this concern with structures and organisation has continued (Peckham et al 2016). Financial insecurity created additional problems with LAs sometimes unsure of the details of their financial settlement from government until many contracts had been negotiated. Budget cuts across other departments within LAs also brought pressures to public health teams, as costs were transferred and shared across departments. Similarly contracts have received new scrutiny, and both existing and new contracts have had to be (re)negotiated within a new provider landscape.

The organisational position of the public health team and the director of public health were also found to be important in terms of ability to influence strategic decision-making and work with other departments. System co-ordination remained an area where roles and responsibilities of various actors were not always clear. In addition, actors within the system had to negotiate ways of working with others, in a situation where much was new and still changing. This was further complicated in two–tier council areas where responsibilities are spread between organisations creating additional complexities of inter-organisational working. However, our surveys (Jenkins et al 2015Jenkins et al 2016) showed public health teams in two-tier authorities appeared to have fewer capacity issues in terms of supporting the information needs of CCGs.

Our research provides an early overview of the development of the public health system in England (2013-15) and highlights some important issues that have both policy and practice implications including:

  • support for a stronger LA role in public health;
  • a system still in flux and some continuing confusion about organisational responsibilities in terms of commissioning;
  • financial constraint impacting on capacity of public health teams alongside broader financial constraint in local government;
  • competing policy objectives; an ongoing struggle between local agendas (e.g. tackling inequalities) and a central government push (e.g. towards integration);
  • some innovation and creativity in using public health resources, but also some concern expressed about inappropriate use of public health funding;
  • the development of collaborative work between some LA departments, but some poor linkages with CCGs;
  • distinct differences in development across our sites.

Overall, our findings suggest that the development of the new public health system in England is still in progress with both the internal organisation of public health in LAs, the NHS and PHE in a continuing state of flux. Despite much activity around the re-organisation of systems, structures and processes, which have had important consequences for roles, relationships and functions, we haven’t seen a corresponding shift in priorities and strategies. We identified a mismatch between the rhetoric at policy level, emphasising the importance of prevention and the reality, which has seen cuts in public health funding.  We found that the Health and Social Care Act (2012) and associated policies paid insufficient attention to the nature and quality of relationships across the various organisations and individuals that constitute the new public health system. As a result, some of the challenges identified during the passage of the Health and Social Care Bill have been averted, although many remain. Some of the opportunities identified have been realised, but many are highly dependent on a range of locally contextual factors.

Our findings also mirror those set out in another recent blog, where Brackley argues that more work is needed to recognise the value of public health professionals within local authorities, the long term benefits of the prevention agenda and that “interventions that cannot easily be measured – at least in the short-term – in pounds and pence” are important.

For more details and a wider discussion of our data and finding refer to our final report which has just been published.

Refs

James Brackley (2016) ‘Everything is public health’: opportunity or threat for local public health professionals? 24/5/16

Erica Gadsby, Stephen Peckham, Anna Coleman, Julia Segar, Neil Perkins, Linda Jenkins, and Donna Bramwell. (2014) PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined: First interim report: the scoping review. University of Kent, PRUComm.

L.M. Jenkins, D. Bramwell, A. Coleman, E.W. Gadsby, S. Peckham, N. Perkins, J. Segar (2015). Integration, influence and change in public health: findings from a survey of Directors of Public Health in England. Journal of Public Health Advance Access published October 20, 2015.

Stephen Peckham, Erica Gadsby, Anna Coleman, Linda Jenkins, Neil Perkins, Donna Bramwell, Jayne Ogilvie, Harry Rutter and Julia Segar (2016). PHOENIX: Public Health and Obesity in England – the New Infrastructure Examined: final Report. University of Kent, PRUComm.

Nick Riches, Anna Coleman, Erica Gadsby and Stephen Peckham (2014) The role of local authorities in health issues: a policy document analysis. Kent University, PRUComm.