Healthcare commissioning is the process by which population needs are assessed, and appropriate health care is purchased to meet those needs from organisations providing care. Introduced in the NHS in 1990, this separation between the roles of planning and purchasing care on the one hand and providing care on the other, is claimed to support an effective and efficient health system. In 2012 there was a significant reorganisation of the NHS in England (enacted in the Health and Social care Act 2012 (HSCA12)), with the abolition of some organisations, the creation of others and a significant redistribution of responsibilities for commissioning different types of healthcare. The changes were comprehensive, affecting most types of organisation in the NHS. Not only was there a wider variety of types of organisation in the new system, but also responsibilities for commissioning some types of services were divided between a number of different organisations. These changes (and other aspects of the reorganisation) were intended to: give front line NHS clinicians more freedom and a greater role in commissioning; increase the efficiency of the NHS by promoting greater competition between providers; focus commissioning activity upon achieving particular outcomes rather than on counting activity; create a new Arm’s Length Body (NHS England) to oversee the running of the NHS; and to transfer responsibility for public health to elected Local Authorities. In order to investigate the impact of the changes in respect of commissioning, we undertook a three year study using qualitative and quantitative methods to explore how the new commissioning system was functioning. This research aimed to assess the impact of the reforms on the operation and outcomes of the commissioning system.
The Health and Social Care Act 2012 (HSCA 2012) introduced major changes into the commissioning system for the English NHS in 2013. Primary Care Trusts (PCTs) were replaced with Clinical Commissioning Groups, clinically-led statutory bodies responsible for the planning and commissioning of health care services for their local area. A new arms-length body, NHS England (NHSE), was established with responsibility for overseeing the work of CCGs. Commissioning responsibilities for local populations are now divided between CCGs, local authorities and NHSE. Since the HSCA 2012 took effect, there have been several
important policy developments, which affect the ‘new commissioning system’.
In 2014, The Five Year Forward View (5YFV) focussed on how organisations in the NHS need to cooperate with each other, and form new configurations known as ‘new care models’ (NCMs), the first wave of which have been designated ‘Vanguards’. There are also other organisational and service delivery changes being implemented across the country, designed to improve the integration of care. These changes take a range of forms including both horizontal and vertical integration.
In 2015, the relevant NHS national bodies issued a further policy document introducing the concept of local cooperative, place based planning, initially known as Sustainability and Transformation Plans and from March 2017 Sustainability and Transformation Partnerships (STPs). Despite these developments, there have been no relevant legislative changes, so the HSCA 2012 provisions concerning the respective roles of NHS commissioning organisations and the regulatory framework in respect of both procurement and provider competition remain in force. There is now a more complex local landscape of organisations all of which need to be involved in the planning of local services; and CCGs need to be able to find ways to engage with them effectively. This project investigated the initial stages of this process.
The questions addressed by the research were:
How are CCG internal processes of decision making changing?
What is the role of the individual CCG in the current commissioning landscape?
How is accountability maintained by CCGs in the current commissioning landscape?
How is competition and the current pricing regime relevant to CCGs’ commissioning decisions?
Research evidence note prepared by Prof Kath Checkland, Policy Research Unit in Commissioning and the Health Care System, University of Manchester, Feb 2017, updated Oct 2018
Disclaimer: this note is a brief summary of relevant evidence, prepared in response to a request for a rapid summary from DHSC colleagues. It is not a comprehensive summary of all available evidence.
This is an issue which has been considered many times over the past decades. When first created in 2003, Primary Care Trusts covered populations of approximately 100,000 – this increased to 300,000 due to mergers in 2005. When CCGs were created in 2013, no specific ‘ideal’ size was stipulated. CCGs vary greatly in size, covering populations from approximately 800,000 to less than 100,000. 212 CCGs went ‘live’ in 2013 – that number has not materially changed since then.
The issues which are usually considered when thinking about size of commissioning organisation are:
Large enough to pool the risk associated with rare or expensive treatments
Large enough to have ‘clout’ to influence provider behaviour
Small enough to understand the needs of the local population and local provider landscape
The best size to minimise running costs
Size and performance
The evidence is clear that there is no obvious association between size and measures of performance.
I am aware of two main studies of this topic:
1. Wilkin, D., Bjoke, C., Coleman, A. & Gravelle, H. (2004), The relationship between size and performance of primary care organisations in England. Journal of Health Services Research and Policy, 8, pp. 11-18.
Objectives: To examine the relationship between the size and performance of primary care organisations, the effect of and the reasons for mergers.
Methods: Data on size, proxy measures of performance and merger intentions for 71 organisations were extracted from telephone and mail surveys of primary care groups and trusts (PCG/Ts).
Results: Of the 22 performance measures examined, only two were significantly associated with size, and over half were not associated with any of the potential explanatory variables. Most organisations (70%) were planning mergers. If all planned mergers take place, the mean size of primary care organisations will double to nearly 200 000. The main reasons for mergers were to make better use of resources and for PCGs to become PCTs.
Conclusions: There is little evidence that the performance or efficiency of a primary care organisation is associated with its size. Optimal size may differ for different functions. Mergers are seen as a way of increasing management capacity and may reflect the desire of managers to manage large organisations. There is a risk that larger primary care organisations will recreate hierarchies and lose local ownership and participation.
2. Greaves, F., Millett, C., Pape,U., Soljak, M. and Majeed, (2012) Association between primary care organisation population size and quality of commissioning in England:an observational study. British Journal of General Practice DOI: 10.3399/bjgp12X616364
Background: The ideal population size of healthcare commissioning organisations is not known.
Aim: To investigate whether there is a relationship between the size of commissioning organisations and how well they perform on a range of performance measures.
Design and setting: Cross-sectional, observational study of performance in all 152 primary care trusts (PCTs) in England.
Method: Comparison of PCT size against 36 indicators of commissioning performance, including measures of clinical and preventative effectiveness, patient centredness, access, cost, financial ability, and engagement.
Results: Fourteen of the 36 indicators have an unadjusted relationship (P<0.05) with size of the PCT. With 10 indicators, there was increasing quality with larger size. However, when population factors including deprivation, ethnicity, rurality, and age were included in the analysis, there was no relationship between size and performance for any measure.
Conclusion: There is no evidence to suggest that there is an optimum size for PCT performance. Observed variations in PCT performance with size were explained by the characteristics of the populations they served. These findings suggest that configuration of clinical commissioning groups should be geared towards producing organisations that can function effectively across their key responsibilities, rather than being based on the size of their population alone.
Size and purpose
Those who have studied commissioning qualitatively (including our own work and that of Smith, Mays et al (2013) and the Nuffield Trust (Curry, Goodwin et al. 2008)) tend to conclude that the different population sizes are required for different purposes. Thus, for example, considering the configuration of services for rare or expensive diseases requires a population size large enough to absorb the risk of small numbers of patients costing a great deal. However, whilst commissioners sometimes argue that larger organisations are required to counter the power of large providers, this is not associated with any demonstrable change in outcomes. Many of the things that commissioners are able to influence in a significant way require fine-grained local knowledge (Coleman, Checkland et al. 2009, McDermott, Checkland et al. 2016), which requires smaller organisations with real legitimacy amongst their colleagues. Thus, for example, supporting GPs to manage demand, reducing prescribing costs, managing access etc requires commissioning organisations with clear local roots. Our study of the early stages of primary care co-commissioning (http://blogs.lshtm.ac.uk/prucomm/files/2016/04/CCG3-interim-report-v8.2.pdf) showed that the attempt by NHS England to commission primary care at national level resulted in a transactional form of commissioning, unable to respond to the nuances of local conditions and problems.
Size and costs
Primary Care Trusts (PCTs) had the freedom to allocate resources to running costs as they saw fit, and these costs varied. These costs seem to have been in the region of approximately £25-£35/head of population, although I do not have exact figures for this. When CCGs were created in 2012, running costs were fixed at £25/head, and this has subsequently been reduced to £22/head. CCGs are encouraged to contract out managerial functions to very large Commissioning Support Units. The extent to which they do this varies (Petsoulas, Allen et al. 2014), but the functions contracted out tend to be those most amenable to economies of scale, such as back office functions, data management and analysis etc. Increasing the size of CCGs would therefore yield minimal additional savings in managerial costs.
The evidence suggests that there is no obvious ideal size of commissioning organisation. Commentators have suggested that what is required are flexible arrangements and regulations that allow organisations to work together across different scales depending upon the type of service involved and the degree of financial risk. Studies of service reconfiguration suggest that local context is very important (Turner, Allen et al. 2011), and it is therefore vital that organisations responsible for significant service changes are local enough to both have legitimacy and to understand the context. There is little scope under current regulations for further economies of scale with regards to managerial or administrative costs.
Coleman, A., K. Checkland, S. Harrison and G. Dowswell (2009). Practice-based Commissioning: Theory, implementation and outcome. Final report. University of Manchester, National Primary Care Research and Development Centre.
Curry, N., N. Goodwin, C. Naylor and R. Robertson (2008). “Practice-based Commissioning: reinvigorate, replace or abandon?” The Kings Fund.
McDermott, I., K. Checkland, A. Coleman, D. Osipovič, C. Petsoulas and N. Perkins (2016). “Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS.” Journal of Health Services Research & Policy22(1): 4-11.
Petsoulas, C., P. Allen, K. Checkland, A. Coleman, J. Segar, S. Peckham and I. McDermott (2014). “Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England.” BMJ Open4(e005970).
Smith, J., S. E. Shaw, R. Rosen, A. M. D. Porter, I. Blunt, A. A. Davies, E. Eastmure and N. Mays (2013). Commissioning high quality care for people with long-term conditions, NIHR Service Delivery and Organisation Research Programme.
NHS England are currently conducting a review of the Quality and Outcomes Framework (QOF). One of the key areas for investigation is the potential impact of removing the incentives on the quality of care delivered in general practice. There is little evidence on the impact of removing financial incentives and the available evidence is inconclusive. There has been limited national monitoring of the consequences of the indicators that have been removed from the QOF in England in recent years.
This project aimed to analyse the effect of indicator removal in a large, nationally-representative cohort of patients whose care quality has been consistently recorded over time. The research provides intelligence on the likely patient impacts of changing existing incentives. This is key to understanding the risks of change, but also what the change in practice activity has been as a consequence of removing incentives.
The number of GPs who say they are likely to quit direct patient care within five years rose to 39% in 2017 from 35% in 2015, according to a new survey carried out by University of Manchester researchers.
The figure rose from 61% in 2015 to 62% in GPs over 50. Among this group, the majority said it was highly likely (47%) or considerably likely (15%).
In contrast, 13% of GPs under 50 said there was a considerable or high likelihood of leaving direct patient care within five years and 45% reported that there was no likelihood.
More than nine out of 10 GPs reported experiencing considerable or high pressure from ‘increasing workloads’.
Although there has been relatively little change between 2015 and 2017, average reported pressures remain at a high level relative to previous surveys.
Particularly high average levels of pressure were reported in ‘having insufficient time to do the job justice’, ‘increasing workloads’, ‘paperwork’ and ‘increased demand from patients’.
The National GP Worklife Survey is a national survey of GPs in England, which has been carried out nine times since 1999.
It analyses two samples in 2017: 996 GPs responded to a random sample of 4000 people and 1,199 responded (out of 22280) after being followed up after responding to the 2015 survey.
Also in the survey, overall job satisfaction has increased slightly since the previous survey in 2015, though levels of satisfaction in 2015 were the lowest since 2001.
Satisfaction with aspects of the job, such as remuneration, hours of work and amount of responsibility given, although slightly higher than in 2015, remain lower than in the surveys undertaken before the introduction of the new GP contract in 2004.
The respondents reported working an average of 41.8 hours per week. Stated working hours per week have remained largely stable since 2008. 36% said they worked fewer than 40 hours per week, 28% between 40-49 hours, 16% reported working between 50-59 hours and 20% reported working 60+ hours per week.
The percentage of respondents earning £110,000 per year or more fallen from 34.6% in 2010 to 31% in 2015 and rose to 32.5% in 2017; their median hours worked per week increased between 2010 and 2017.
Professor Kath Checkland, who led the study said: “Our survey shows there has been little change in the satisfaction and stressor results between 2015 and 2017 survey, though 2015 were already at very high levels.
“Although the declines in satisfaction seen between previous years has stopped, low satisfaction and high pressures have been sustained.
“The all-time high figure of 39% of GPs who say they intend to quit within 5 years is particularly worrying in terms of the possible implications it might have on recruitment, retention and patient care.”
Ninth National GP Worklife Survey, 2017, is carried out by the Manchester Centre for Health Economics at The University of Manchester on behalf of the Policy Research Unit in Commissioning and the Healthcare System (PRUComm). PRUComm is funded by the Department of Health and Social Care Policy Research Programme.
This report is independent research commissioned and funded by the National Institute for Health Research Policy Research Programme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care or its arm’s length bodies, and other Government Departments
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An electronic version of the report is available here.
The Health and Social Care Act 2012 gave the power and responsibility for commissioning health services and budgets to groups of GP practices called Clinical Commissioning Groups (CCGs). CCGs will commission the great majority of NHS services for their patients but will not be directly responsible for commissioning services that GPs themselves provide. The responsibility for commissioning primary care services (medical, dental, eye health, and pharmacy) was given to a new statutory organisation called NHS England (NHSE), known as the NHS Commissioning Board in statute. This was to ensure a more standardised model and consistency in the management of the four groups.
In May 2014, following Simon Stevens appointment as the Chief Executive of NHS England, CCGs were delegated the responsibilities to commission primary care services. This was to enable better integrated care outside hospitals, ensure that primary, community and mental health are properly resourced, and CCGs having more influence over how funding is invested for local population, which would ensure sustainability of their local NHS. Co-commissioningwould also enable the development of new models of care such as multispecialty community providers (MCPs)and primary and acute care systems (PACSs), as set out in the NHS Five Year Forward View.
This report presents the findings from a study following the development of Clinical Commissioning Groups (CCGs) in England. This is the third phase of the project, which aims to understand the ways in which CCGs are responding to their new primary care co-commissioning responsibilities from April 2015, providing feedback to NHSE supporting CCGs going through the approval process.
The study provides detailed evidence about the experiences of CCGs as they took on delegated responsibility for primary care commissioning. The study took place between May 2015 to June 2017. The strength of this study lies in the bringing together of evidence from senior policy makers as to the overall objectives for the policy with both telephone survey and case study evidence as to how it is playing out in practice. The specific research questions addressed in this report are:
What is the scope of co-commissioning activity and the process of change?
What approaches have been taken by CCGs to:
Develop governance structure to oversee primary care co-commissioning?
Commissioning and contracting?
Manage and develop the relationships between CCGs and their membership and between CCGs and external stakeholders?
Manage conflicts of interest?
What are the impacts and outcomes CCGs would expect from taking on delegated responsibility and claims of early successes?
What factors have affected CCGs’ progress and development?
It is generally agreed that access to high-quality primary care is vital in the quest to provide the best possible health care at the lowest cost. Finding new ways to deliver and extend access to primary care services is of high priority in many health systems. The UK is no exception, and the past 30 years has seen a wide range of initiatives focused on primary care—particularly services provided by primary care physicians: GPs. Some initiatives have focused on payment models, altering contracts in an effort to change behaviour. Others have focused on the planning side, repeatedly enlarging, shrinking and reorganizing the organizations with responsibility for commissioning/purchasing primary care services on behalf of a population. In this paper we explore the latest of these policy and organizational changes, presenting the findings from an empirical study investigating recent changes to the commissioning of primary care services in England. Using an historical account of mechanisms to plan and manage GP services in England, we identify some of the issues involved. We explore the espoused logic underpinning the current reforms, and present early evidence about their implementation, highlighting the extent to which they may meet official aims and address the identified issues. The contribution offered is twofold:
First, we offer an account of the development of planning and management of GP services in England, bringing clarity to a complex field and providing valuable evidence for those responsible for overseeing primary care services in the UK and internationally.
Second, our exploration of the implementation of the latest round of reforms provides some lessons about the interplay between local, regional and national planning, and about the ways in which policy is made and implemented.
Since the establishment of PRUComm in 2011 our research has focused on examining how the changes to the English NHS and public health system have developed. We continue to examine the development of CCGs and the new commissioning structures. We have also been exploring the mechanisms by which commissioning is undertaken, such as contracting and the use of competition and cooperation within the new system.
While most media attention has focused on changes to the commissioning and delivery of healthcare, the shift of public health to local authorities was a major part of the reforms introduced in April 2013. We have examined the progress and developments in the public health system with a particular emphasis on how governance and organisational structures develop and whether being embedded within local councils changes the way that public health services are provided. We have also been focusing on primary and community health care with recent projects examining general practice – including methods of funding primary care; research on recruitment and retention; QOF, scaling up primary care and running and analysing two rounds of the GP WorkLife survey (eight and nine).
Our research on CCGs has most recently focused on primary care co-commissioning and new forms of contracting, such as outcomes-based and alliancing. Given the increasing policy emphasis on this area of healthcare we anticipate that we will be increasingly involved in further research on primary and community healthcare. All these topics will be explored in today’s seminar with presentations by researchers from PRUComm.
In 2016 we reported our research on NHS commissioners’ and providers’ understandings and use the rules on competition, and our investigation of how commissioners used competitive and cooperative commissioning mechanisms at local level from 2013 to 2015. Since 2015, when the last phase of field work was undertaken, the legal framework governing the procurement of clinical services has not changed. The generally pro-competitive provisions of the Health and Social Care Act 2012 (HSCA 2012) remain in force. In addition, the Public Contracts Regulations 2015 (PCR 2015) came into force in April 2016 introducing further requirements in respect of competitive procurement. Despite no substantive changes in the legislation governing procurement processes, since 2015 there has been a considerable national policy shift towards cooperative methods of commissioning.
Firstly, the ‘Five Year Forward View’ (5YFV) published by the NHS England (NHSE) in October 2014 instigated a number of the New Models of Care (NMC) vanguard sites. Many of these involved the merger or at least closer cooperation of a range of NHS organisations. This view was reinforced by the national planning guidance issued in late 2015 (Delivering the Forward View: NHS Planning Guidance 2016/17-2020/21). This document stated that the NHS should concentrate on local, placed based planning to be achieved by cooperation between local stakeholders. The plans were to be called ‘Sustainability and Transformation Plans’, and the groups of organisations were named ‘Sustainability and Transformation Partnerships’ (STPs). These cooperative modes of coordination were regarded as the preferable (and in fact, mandated) method by which health services would be planned and commissioned. Lastly, the notion of Accountable Care Organisations (ACOs) or Systems (ACSs) was introduced in 2017. These were seen as natural successors to STPs under which NHS organisations would either merge formally or work in close cooperation. In the light of these policy developments there was a need to investigate the way in which local commissioners and providers managed the interplay between cooperation and competition in commissioning clinical services.
The aims of this stage of the field work remained the same as those of the initial study. The 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 (CHS).
The English Health and Social Care Act 2012 gave GP-led clinical commissioning groups (CCGs) responsibility for commissioning the majority of healthcare services for their registered population. However, responsibility for commissioning primary care services was given to a new national body, NHS England (NHSE), to avoid conflicts of interest and because of a perceived need for a standardised and consistent approach to commissioning. It soon became apparent that NHSE was struggling to move beyond a transactional approach to commissioning, focused on payments and contract management. When Simon Stevens took over as the Chief Executive of NHSE (April 2014), he advocated transferring responsibility for commissioning primary care services from NHSE to CCGs. Two years on, how have CCGs responded to their new responsibilities and what challenges do they face?