Tag Archives: commissioning

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.

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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>>

PRUComm Research Review 2017

This is our fifth annual review of research and provides a brief overview of our research activities. Following confirmation last year of our extension until the end of 2018 we have now agreed a programme of work with the Department. This sees a stronger shift towards exploring the impact of system changes on commissioning. The introduction of Sustainability and Transformation Plans and new metapractice organisations creates a rapidly shifting landscape for the commissioning and delivery of healthcare in England.

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Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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] >>

Alliance contracting, prime contracting and outcome based contracting: What can the NHS learn from elsewhere? A literature review

This report is part of the research of the Policy Research Unit in Commissioning and the Health Care System (PRUComm) on new models of contracting in the NHS, commissioned by the Department of Health.

Over the past few years the need to find new ways to integrate services has become an important policy priority in the English NHS. The formation of new organisational configurations in local health economies announced in the Five Year Forward View entails separate organisations working closely together to improve the integration of local services and allow the better use of resources. One way to achieve collaboration across organisational boundaries is through the adoption of new models of contracting, such as alliance contracting, prime provider contracting and outcome based contracting. Despite their relative novelty in the English NHS, these models have a history of use in other sectors such as construction and defence, as well as in the commissioning of public services in the UK and overseas.

This report summarises the findings of a literature review of the available evidence concerning the characteristics of these new contractual models and their implementation in other sectors. The available evidence is considered in order to draw out the lessons which may be learnt to aid the implementation of these models in the English NHS.

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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.

Link to the paper>>

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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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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