Category Archives: CCG

PRUComm Research Review August 2016

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

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Interrogating institutional change: Actors’ attitudes to competition and cooperation in commissioning health services in England

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers’ views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers’ understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.

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Engaging GPs in commissioning: Realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

Objectives To explore the ‘added value’ that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives.

Methods Realist evaluation. We identified the programme theories underlying the claims made about GP ‘added value’ in commissioning from interviews with key informants. We tested these theories against observational data from four case study sites to explore whether and how these claims were borne out in practice.

Results The complexity of CCG structures means CCGs are quite different from one another with different distributions of responsibilities between the various committees. This makes it difficult to compare CCGs with one another. Greater GP involvement was important but it was not clear where and how GPs could add most value. We identified some of the mechanisms and conditions which enable CCGs to maximize the ‘added value’ that GPs bring to commissioning.

Conclusion To maximize the value of clinical input, CCGs need to invest time and effort in preparing those involved, ensuring that they systematically gather evidence about service gaps and problems from their members, and engaging members in debate about the future shape of services.

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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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Changing the ties that bind? The emerging role and identity of GPs and managers in CCGs

By Julia Segar

With national elections looming, political parties are setting out their electoral stalls and buffing up their manifestos.  We can be confident that all will pledge their support for the NHS and affirm their belief in the principle of healthcare for all, free at the point of delivery. Our national attachment to the NHS was enacted for the international media in the summer of 2012 when London hosted the Olympic Games. The memorable opening ceremony featured key moments in British history and cultural life including a tribute to the NHS. This segment drew attention and puzzlement from international media but highlights the extent to which the NHS is an institution that is deeply embedded in British society. It is something that most of us take for granted.

2012 brought us the Olympics and it also saw the passing of the Health and Social Care Act 2012 (HSCA 2012). This legislation set in motion a reorganisation of the English NHS said to be the most profound since its inception in 1948. At its heart was the abolition of managerially led PCTs and the transfer of responsibility for commissioning to groups of GPs working together in Clinical Commissioning Groups (CCGs).  There are now 211 CCGs in England responsible for a budget of £65 billion or 60% of the total NHS budget (Wood and Heath 2014). GPs now lead the process of planning, designing and purchasing health services for their local populations. The rationale for this was the notion that GPs are on the ‘frontline’ of patient care so they know and understand their patients’ needs and in turn are trusted by their patients. We (HiPPO and PRUComm) have been tracking and researching these changes and in our Sage Open paper we examine the impact of these reforms on the roles and identities GPs and managers.

There is much academic interest in the nature of institutions and how they change. Scott (2008) suggests that institutions have three constitutive pillars: the regulative, the normative and the cognitive-cultural. We have used Scott’s theory of institutions to examine the changes taking place as GPs have formed themselves in CCGs and taken on commissioning responsibilities.  The regulative pillar of institutions refers to rules, regulations and sanctions and these are fairly clear to apprehend. The reforms put in place by HSCA 2012 have clearly brought about far reaching change in the the NHS. The normative pillar of an institution refers to the norms and valued held by individuals and the resulting behaviour that ensues. So here our interest has been in roles of GPs and managers and how these have shifted in the wake of reforms. Scott’s cognitive-cultural pillar is the least tangible and refers to the meanings associated with institutional life, so these are often things that we take for granted and only notice when profound change brings them to our attention.  If we travel abroad and encounter different healthcare systems we become conscious of our own “cultural templates” of how healthcare works here at home.

As GPs take on increasing managerial responsibility we look at the shifts in their roles, the demands on their time and potential changes in relationships with peers and with patients. Likewise we look at shifts in responsibilities for managers as their positions change and as job losses are absorbed. As CCGs develop and as roles of GPs and managers change we examine whether with changing roles comes shifts in identities and in the way that GPs and managers relate to the institution of the NHS. We pose the question as to whether these changes begin to erode the cognitive-cultural pillar of the institution and change the ties that bind GPs and managers to the NHS.

The research was carried out as part of the programme of the DH-funded Policy Research Unit in Commissioning and the Healthcare System (PRUComm).

Disclaimer: this research was funded by the Department of Health. The views are those of the authors.

References

Scott, W. R. (2008). Institutions and organizations: ideas and interests. Los Angeles, London, New Delhi, Singapore, Sage Publications.

Wood, J. and S. Heath (2014). “Clinical commissioning group (CCG) funding.” Social and General Statistics and Social Policy Section House of Commons Library (Standard Note: SN06779).

Make, buy or ally? Commissioning support in the new NHS

BY KATH CHECKLAND

Unless you work in a Clinical Commissioning Group (CCG) or obsessively follow the medical press, it is quite likely that you have never heard of a Commissioning Support Unit (CSU), but when you go to the doctor or attend a hospital appointment there is a high chance that someone from a CSU somewhere will have played a role in the care you receive. From ensuring that GPs receive the payments they are entitled to, to negotiating contracts with hospitals, and from gathering data about care quality to providing IT support to practices, CSUs are an important part of the new architecture of the NHS. Set up following the enactment of the Health and Social Care Act in 2012, CSUs were originally intended to be ‘standalone’ organisations, ‘spun off’ into the private or third sector and competing to provide high quality commissioning support services to CCGs.  The intention behind the policy was to build upon the tentative moves which had been made during the 2000s to broaden the range of support available to commissioners, bringing in experts from the private and third sectors as external consultants for Primary Care Trusts. So-called ‘FESC’ (Framework for External Support for Commissioning) providers offered PCTs niche services such as service redesign, data analysis or support for Practice-based Commissioners.  Building on this experience, CCGs were established as managerially lean, bringing to the foreground clinical expertise and expected to ‘buy in’ the more technical expertise required to commission effectively. Experienced commissioning staff from PCTs who did not immediately take up roles in CCGs were transferred to a Commissioning Support Service, and these were established as Commissioning Support Units hosted by NHS England once the HSCA came into force.  Their short life has been somewhat turbulent, with the Health Service Journal regularly reporting mergers, crises and concerns. The pace of ‘outsourcing’ from the NHS has been slowed, with acknowledgement that we are some way from a ‘mature’ market in such services .

Against this background, it is important to start to explore how this new model of commissioning is playing out in practice. Whilst the stated objective of widening the base of expertise that commissioners can use to help them do their job as effectively as possible seems unobjectionable, the reality is not necessarily quite so straightforward. Our recent CCG research published in BMJ Open  explored the early stages of this transition, using contracting theory to try to understand how CCGs were approaching the decisions they needed to make: should they ‘make’, ‘buy’ or ‘ally’? We found that some CCGs were reluctant to outsource commissioning support, fearing that they would lose local knowledge and trusted local relationships. CSUs are large organisations (following recent mergers, there are only 19 in England) and CCG staff told us that they were concerned that CSU staff wouldn’t understand their local service needs. Others were disappointed by the absence of real choice, and saw CSUs as a re-creation of PCTs. Many expressed doubts that outsourcing commissioning support would reduce costs, and expressed an intention to build longer term relationships with trusted partners in order to minimise transaction costs. How all this plays out in the longer term is a matter of conjecture; what seems clear, however, is that the original vision of CCGs buying support from a range of independent providers is some way from realisation.

Kath Checkland is a Reader in Health Policy and Primary Care. She leads the Health Policy, Politics and Organisations group (HiPPO) in the Centre for Primary Care, University of Manchester.

Disclaimer: this research was funded by the Department of Health. The views are those of the authors.

Just what the Doctor ordered? The ‘added value’ GPs bring to clinical commissioning

BY NEIL PERKINS

Our new journal paper published by the British Journal of General Practice looks at what ‘added value’ GPs think they bring now they are responsible for commissioning healthcare in their local communities.  A key assumption underpinning CCGs is that GPs ‘add value’ to commissioning centred on their intimate knowledge of their patients.

The coalition government’s 2012 Health and Social Care Act abolished Primary Care Trusts (PCTs) and Strategic Health Authorities in England, replacing them with Clinical Commissioning groups (CCGs).These are clinically led organisations which became responsible for the care of the population within their geographic boundaries on April 1st 2013. CCGs are now responsible for 65% of the overall NHS budget, commissioning routine and emergency care. Another new body – NHS England (NHSE) – oversees CCGs and is responsible for commissioning services such as primary care and specialised services at a national level. At the heart of the new arrangements is the desire by government to increase competition, reduce bureaucracy and most importantly, a desire to increase clinical leadership in the NHS.

Our interviews with clinicians and managers revealed a range of claims concerning GP added value:  they centred on their proximity to patients and on the value of their clinical knowledge.  Firstly,GPs are in the position of knowing patients’ real experiences of all aspects of the services provided by the NHS. Furthermore, GPs can quickly see any common factors from patients’ feedback such as the lack of service provision in any areas. GPs also understand patients’ needs and wants and what services and support they require and when. As such, they can understand where service provision needs to be enhanced or altered to better reflect patients’ needs.

Secondly, clinical knowledge and input were seen as critical, not so much in the detail about particular treatments, but in the way that the greater involvement of people with clinical knowledge changed the focus of discussions. In the PCT, there may have been more of a focus on such things as finance and costing by managers, and not whether a service is performing to expectations or the clinical value of the service. It was claimed that the emphasis now has now shifted to a more clinical focus with GPs in the CCG.

Implications for research and practice

Our paper reports opinions and it is clear that those closely involved in CCGs are convinced of the value of what they do. The crucial question now is the way in which these beliefs, aims and aspirations play out in practice. Clinicians have been involved in commissioning before: do the new structures better enable the effective wielding of GPs’ knowledge in the commissioning process? Focusing upon the knowledge that individuals bring raises questions about whose voices are heard. Our respondents were largely drawn from the ranks of senior clinicians; if these are the only voices heard then there is danger that wider evidence will be ignored. CCGs will need to find ways of bringing in other voices, including their own rank and file as well as public health and others.   Finally, research needs to explore in more detail the extent to which GP voices are needed in the day to day running of the CCG and on what they are needed for. Our respondents spoke feelingly of the workload they faced. It is clearly unsustainable to have GPs everywhere and present on every occasion, and what might be called the ‘smart use’ of GP knowledge must be the aim.

Neil Perkins is a Research Associate in the HIPPO team (Health policy, politics and organisation group), part of the Centre for Primary Care in the Institute for Population Health at the University of Manchester

Disclaimer: The research for this paper is funded by the Department of Health. The views expressed are those of the researchers and not necessarily those of the Department of Health.