Commissioning through Competition and Cooperation

Following several versions of the NHS quasi market since 1990, a wide ranging set of reforms was introduced into the NHS under the recent Coalition government by the Health and Social Care Act 2012 (HSCA 2012). The idea behind these is the same as that behind previous versions of the NHS quasi market: that competition between a wider range of providers will produce the desired results of improved quality and greater efficiency. The HSCA 2012 made a direct correlation between competitive behaviour in the NHS and competition law. The Procurement, Choice and Competition Regulations No.2 2013 relate to sections 75-77 and 304 (9) and (10) of the HSCA 2012, and indicate that competitive procurement by commissioners is to be preferred, although not in all circumstances. Monitor (the former NHS Foundation Trust regulator) took on the role of economic regulator for the whole of the NHS. Along with the national competition authorities (being, since April 2014 the Competition and Markets Authority, and prior to that, The Office of Fair Trading and the Competition Commission), has powers to enforce competition law to prevent anti-competitive behaviour.

At the same time, it is still necessary for providers of care to cooperate with each other in order to deliver high quality care. There are many aspects of care quality where cooperation is needed, such as continuity of care as patients move between organisations, and sharing of knowledge between clinicians. Monitor is also responsible for promoting co-operation. It is the role of NHS commissioners (including Clinical Commissioning Groups ‘CCGs’), however, to ensure that the appropriate levels of competition and cooperation exist in their local health economies.

During the course of this study, an important policy document, The Five Year Forward View (5YFV) was published by NHS England in October 2014. This did not mention competition between organisations and instead focussed on how organisations in the NHS need to cooperate with each other, and in fact at times merge to form larger organisations. And it should be noted that there have been no relevant legislative changes, so the HSCA 2012 remains in force. While studies have noted that incentives for competition and cooperation exist in healthcare, few have researched the interaction between the two. There was a need to investigate the way in which local health systems were managed to ensure that cooperative behaviour was appropriately coexisting with competition.

This project aimed to investigate how commissioners in local health systems managed the interplay of competition and cooperation in their local health economies, looking at acute and community health services (CH).

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Understanding primary care co-commissioning: Uptake, scope of activity and process of change

The Health and Social Care Act 2012 gave the responsibility for commissioning primary care services to NHS England (NHSE). Part of the rationale for this was to move towards a more standardised model of primary care commissioning. However, it has become clear since 2010 that local flexibility and understanding is also required in order to properly match primary care provision to the needs of an aging population. Primary care co-commissioning was first mooted in the Call to Action in 2014, where “joint commissioning” was identified as one of national level supports to improve general practice. In May 2014, it was officially announced that CCGs would get ‘new powers’ under a new commissioning initiative. There are 3 levels of responsibility; (1) ‘greater involvement’ (where CCGs would have ‘influence’ but not take the lead in shaping primary care locally), (2) joint commissioning (where CCGs would set up a joint committee with NHSE AT), and (3) delegated authority (where CCGs would take over budgets from NHSE Area Teams and take the lead in primary care commissioning). Initially there was no clear expectation that CCGs would move from Level 1 and 2 to taking on full responsibility (Level 3) over time. However, one year on, CCGs operating at Level 1 and 2 were encouraged to consider applying for full delegation. This report aims to explore the uptake of primary care co-commissioning nationally, develop an understanding of the rationale underlying the policy and the expected outcomes, and understand the scope of co-commissioning activity and the process of change.

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Engaging GPs in commissioning: what works?

Via The Commissioning Elf

Within the English NHS, Clinical Commissioning Groups (CCGs) were designed to increase clinical involvement in commissioning – it was thought that GPs’ knowledge of patients’ needs and local health systems would drive more patient-focused commissioning built around local needs.  This new report asks if greater involvement has worked and if so, what specifically has worked?  It could be argued that there is a fair amount of variation across CCGs in terms of clinical engagement so this report asks some pertinent questions.

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Exploring the GP ‘added value’ in commissioning

One of the main focusses of the Health and Social Care Act 2012 (implemented from 2013) was on the development of Clinical Commissioning Groups (CCGs) to replace Primary Care Trusts (PCTs) in commissioning healthcare for their local populations. This report presents the findings from a second phase of our ongoing study following the development of CCGs in England since 2011.

In the first phase of this study (January 2011 to September 2012), we followed the development of CCGs from birth to authorisation i.e. from their involvement in the ‘pathfinder’ programme and officially becoming sub-committees of their local PCT Cluster until their authorisation in April 2013. One of the issues highlighted by our participants in the first phase of the study was the perception of GP ‘added value’. The aim of the second phase of our study was therefore to follow up those claims made in the first phase around issues of GP ‘added value’. We explored further the potential added value that clinicians, specifically GPs, bring to the commissioning process in interviews, and followed this up with observations of commissioners at work.

Our research used ‘Realist Evaluation’ (Pawson & Tilley, 1997). This approach involves: seeking out participants ‘programme theories’ as to how a particular policy or programme will bring about the desired outcomes; exploring the extent to which these programme theories ‘work’ in the real world; and examining in detail the mechanisms and contexts which underpin them. The
approach is often said to be exploring ‘what works, for whom, in what circumstances’? We applied this approach to GPs roles in CCGs, using interviews to find out what CCG leaders believe are the key aspects of their contribution to commissioning. We then observed a wide range of meetings in order to explore the extent to which the claims they made were borne out in practice, and to try to elucidate the important conditions which supported their roles.

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Public Health and Obesity in England – the New Infrastructure Examined

As part of the Health and Social Care Act 2012 (Secretary of State 2012) significant changes to the public health system were introduced. Such changes included: the creation of a new national public health service, Public Health England (PHE); a restored emphasis on the role of general practice in health improvement (DH 2010); the transfer of public health responsibilities from Primary Care Trusts (PCTs) to local authorities; and the creation of Health and Wellbeing Boards (HWBs) as committees of each unitary and upper-tier local authority, where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. As a result of the new arrangements, responsibility for commissioning and delivering public health activities are now split between a number of organisations, including: local authorities, general practice, PHE, NHS England (NHSE) (formally called the NHS Commissioning Board), and voluntary organisations. This potentially means a more complex commissioning and service delivery environment for public health than previously (DH 2011a, DH 2011b).

The PHOENIX project aims to examine the impact of structural changes to the health and care system in England on the functioning of the public health system, and on the approaches taken to improving the public’s health.

This second interim report presents the findings of our phase one case study research and first national surveys of Directors of Public Health (DsPH) and Councillors who lead on public health issues. Download report [pdf]>>

The first national surveys report can be found here.

Eighth National GP Worklife Survey report

Since 1998, The University of Manchester has undertaken regular surveys of the perceptions of GPs in England about their working lives. These surveys provide important independent evidence for the Department of Health, which contributes to informing policy around GP retention and recruitment.

The results of the 8th National GP Worklife Survey are published today. The survey was undertaken in the spring and summer of 2015 and responses were received from over 2,600 GPs.

The respondents reported the lowest levels of job satisfaction since before the introduction of their new contract in 2004, the highest levels of stress since the start of the survey series, and an increase since three years ago in the proportion of GPs intending to quit direct patient care within the next five years.

The survey was carried out by the Manchester Centre for Health Economics in the Institute of Population Health, on behalf of the Policy Research Unit in Commissioning and the Health Care System (PRUComm), and the report is available here (PDF 784KB).

PRUComm Research Review August 2015

Over the last year PRUComm’s research activities have continued to expand culminating in a new phase of work examining co-commissioning of primary care by CGGs and NHS England and additional short research projects on primary care to include new projects on the public health system in England and research on competition and collaboration. We have also continued our research on aspects of the functioning of the health care system with work on contracting and competition and also continued to examine the developing public health system. This is our third annual review of research and provides a brief overview of our current research activities.

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Study on the use of contractual mechanisms in commissioning: Final report

This three year project aimed to investigate how commissioners negotiated, specified, monitored and managed contractual mechanisms to improve services and allocate financial risk in their local health economies, looking at both acute services and community health care.

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The Multiple Purposes of Policy Piloting and Their Consequences: Three Examples from National Health and Social Care Policy in England

Pauline Allen‘s paper looking at policy piloting using three case studies from health and social care was quoted in the Guardian’s article.

Abstract

In England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.

Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the extent to which piloting contributes to the agenda of evidence-based policy-making.

Full paper can be accessed from Journal of Social Policy

Moving Services out of hospital: Joining up General Practice and community services?

This report summarises the findings of a rapid review undertaken by PRUComm of the available evidence of what factors should be taken into account in planning for the closer working of primary and community health/care services in order to increase the scope of services provided outside of hospitals. This report was commissioned by the Department of Health to provide background evidence to support policy development on primary and community health care integration.

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