Tag Archives: NHS

Planning and managing primary care services: lessons from the NHS in England

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.

Read the paper >>

PRUComm Annual Research Seminar

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.

Programme and speakers biographies [pdf]>>

Agenda

9.30 Registration and refreshments

10.00 – Welcome and introduction: Professor Stephen Peckham (Director PRUComm).

10.00 – 10.25 Jonathan Walden: (Commissioning Policy Lead): Policy update – Department of Health and Social Care priorities.  Slides [pdf]>>

10.25– 11.00 Dr Lindsay Forbes: Incentivising GPs: Review of the Quality and Outcomes Framework in England. Slides [pdf]>>

11.00 – 11.20 Coffee

11.20 – 12.00 Dr Jon Gibson and Prof Kath Checkland: Satisfaction, sources of stress and intentions to quit amongst GPs in England: the results of the 9th GP Worklife survey

12.00 – 12.40 Dr Marie Sanderson: Examining the implementation of new models of contracting in the NHS: what are the lessons for the formation of Accountable Care Systems? Slides [pdf]>>

12.40 – 13.20 Lunch

13.20 – 14.00 Dr Valerie Moran: How are CCGs managing conflicts of interest when they commission primary care? Lessons for Accountable Care. Slides [pdf]>>

14.00 – 15.50 Panel Discussion – STPs, and ACS’s the re-emergence of planning?

15.50 – 16.00 Professor Stephen Peckham: Current PRUComm research programme

16.00 Close

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 >>

Read the blog>>

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.

Download report [pdf]>> 

Improving GP recruitment and retention needs a long-term strategy

The state of general practice remains a key talking point in UK healthcare with continuing concerns about difficulty of recruitment, practices closing and a general feeling that general practice is in crisis. The central policy response to this situation is the General Practice Forward View published in April 2016 which was developed from the 2015 10 Point Plan produced jointly by NHS England, the Department of Health, Health Education England, BMA and the RCGP. As part of the development work for the Forward View NHS England and the Department of Health commissioned the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) to undertake an evidence synthesis on GP recruitment, retention and re-employment – although given the paucity of literature on re-employment the review focused on recruitment and retention. The review was undertaken by Professor Stephen Peckham, Director of PRUComm, and Dr Catherine Marchand of the Centre for Health Services Studies at the University of Kent.

Overall, the published evidence in relation to GP recruitment and retention is limited and focused mainly on attracting GPs to underserved rural areas. However, the literature does provide some useful insights to factors that may support the development of specific strategies for the recruitment and retention of GPs. It was also evident that there are clear overlaps between strategies for supporting increased recruitment and retention.

Key factors that are relevant to the recruitment of GPs are primarily related to providing students with appropriate opportunities for contact with and positive exposure to general practice and general practitioners. Having good role models is particularly important and early exposure in pre-clinical training may be important in influencing future medical training choices. The training environment and location of training can also play important roles in improving recruitment to areas where there are shortages of trainees. Financial factors seem less important in influencing student’s choice for general practice – particularly in the current UK context.

More attention could be paid to the fit between skills and attributes with intellectual content and demands of the specialisation – in particular portraying general practice as a stimulating and interesting specialisation. It is also clear that factors such as lifestyle (flexibility, work-life balance, quality of life), social orientation and desire for a varied scope of practice are important factors contributing to decisions about choice of specialisation. Strategies that emphasise what are seen as the most important and rewarding aspects of the GPs job – facilities, autonomy of work, diversity of cases, education and employment opportunities for physician’s spouses in the practice location – all have a positive influence on recruitment.

Interestingly many of the factors relating to retention are similar to those related to recruitment. Positive factors as viewed by students and GPs about general practice as a profession – such as patient contact, variety, continuity of care – are intrinsic to what it means for them to be a GP. Recruitment factors highlighted positive role models, engagement with practices and socialisation into general practice while retention factors are similar in terms of supporting the ability of GPs to practice being a GP.

The evidence does suggest that tackling key aspects of job stress are important but supporting the key factors of how GPs view the essential nature of general practice in terms of patient contact may be more critical together with developing new opportunities for diversity of practice through sub-specialities and broader portfolio careers. As for the new ways of working, it is likely that the inclusion of nurses, pharmacists, and even social workers might help reduce the strain of the workload and burnout symptoms of GPs. GPs leave both for reasons of job dissatisfaction – possibly reflecting a frustration or a disappointment toward the changing roles in their practice – and also to retire before 60 years old, even if not discontent. Reasons may include lack of resilience to deal with stress but also a simple view that they have undertaken sufficient lifetime service. Generally the findings of this review are consistent with the wider literature on organisational behaviour and human resource management.

Based on our analysis of the evidence, the elements that are most likely to increase and influence recruitment in general practice include:

• exposure of medical students to successful GP role models
• early exposure to general practice
• supporting intrinsic motivational factors and career determinants

Despite continuing interest in using “golden handshakes” there is little evidence that financial targeted support will increase recruitment as recent experience in some areas of England have already demonstrated.

While we found no clear evidence of the effect of investment in retainer schemes and incentives to remain in practice on retention things that will possibly influence GPs to remain in practice include:

• supporting intrinsic factors of the job
• strategies to improve job satisfaction
• reducing job stressors such as work overload, lack of support and high demand

Download PRUComm report [pdf]>>

NHSE – IPSOS/MORI report>>

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.

Download report [pdf]>>

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.

Download paper [pdf]>>

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).

Download final report [pdf]>>
Download appendix [pdf]>>