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.
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.
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.
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] >>
This is the fourth annual review of our research and provides a brief overview of our current research activities.
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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.
Link to the paper>>
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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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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Posted in CCG, Commissioning, Competition & cooperation, Publications
Tagged CCGs, commissioning, Competition, Cooperation, FYFV, HSCA, NHS, Procurement
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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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.
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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Professor Stephen Peckham (Director of PRUComm) is the lead author of a recently published NIHR HS&DR funded research which explored the role and impact of patient and public engagement and involvement in commissioning for people with LTCs.
It is estimated that some 15 million people have a long-term condition (LTC) in England and, while the number of people with LTCs is increasing, there have been concerns for a number of years about whether or not the NHS meets their needs. In order to improve the way that the NHS provides services to people with LTCs, successive governments have developed policies to improve the way that NHS plans and organises services and also to strengthen the involvement of patients and the public in decisions about local services. This project examined these developments in three areas of the country focusing on the experience of people with diabetes, rheumatoid arthritis and neurological conditions. We found few good examples of instances where NHS organisations involved patients and the public, but where there was involvement and developments started by patients, these were beneficial for them. The main problems were that the way people were involved was often tokenistic or good ideas were not followed through. Many initiatives started by patients were short term and not sustained. Recent changes in the NHS also meant that existing relationships between NHS organisations and patients were disrupted and people were frustrated at having to start again to develop new relationships with NHS organisations. Essentially, we found that involvement was more successful in places where it was supported and maintained, and where patients could see that it made a difference. However, the process of involvement can be seen as a delicate circle that might be easily broken, leading to people feeling frustrated and disconnected.
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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.