Category Archives: Deputy Director of PRUComm

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>>

Researching policy as it unfolds

BY DR KATH CHeCkland 

One of the first projects that we are doing here at PRUComm is an exploration of the early working and experiences of emerging Clinical Commissioning Groups. This project will deliver a final report in June 2012, and the aim is to provide early learning to inform the ongoing development of CCGs for the DH, policy makers, the new NHS Commissioning Board and GPs and managers in the field.

Researching policy is never easy, as interventions are rarely clearly defined and outcomes are often difficult to both define and assess. In this case these difficulties have been compounded by the fact that the policy is developing and changing as we go along. The ‘pause’ in the legislation, and ongoing amendments to the Health and Social Care Bill in the House of Lords, mean that, even more than usual, we are researching a moving target. However, we do not feel that this means that we should not try. Now, more than ever, we need to use our research expertise to help those who have the difficult task of making the policy a reality on the ground. Exploring the unfolding picture, as it happens and in real time, is challenging and difficult, but it is rewarding, and has the potential to contribute significantly to the policy process. As always, we are immensely grateful to our participants, who are generous in providing access to their organisations, talking to researchers and filling in questionnaires. As for our findings… watch this space!

Dr Kath Checkland is Deputy Director of PRUComm