Ann Mahon

The practice of commissioning healthcare from a private provider: learning from an in-depth case study

BackgroundThe direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services.MethodsA single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative.ResultsThe main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory).ConclusionsThe study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system.

Evaluation of international recruitment of health professionals in England

Objectives: To explore whether a period of intensive international recruitment by the English National Health Service (NHS) achieved its objectives of boosting workforce numbers and to set this against the wider costs, longer-term challenges and questions arising. Methods: A postal survey of all pre-2006 NHS providers, Strategic Health Authorities and Deans of Postgraduate Medical Education obtained information on 284 (45%) organizations (142 completed questionnaires). Eight subsequent case studies (74 interviews) covered medical consultant, general practitioner, nurse, midwife and allied health professional recruitment. Results: Most respondents had undertaken or facilitated international recruitment between 2001 and 2006 and believed that it had enabled them to address immediate staff shortages. Views on longer-term implications, such as recruit retention, were more equivocal. Most organizations had made only a limited value-for-money assessment, balancing direct expenditure on overseas recruitment against savings on temporary staff. Other short and long-term transaction and opportunity costs arose from pressures on existing staff, time spent on induction/pastoral support, and human resource management and workforce planning challenges. Though recognized, these extensive ‘hidden costs’ for NHS organizations were harder to assess as were the implications for source countries and migrant staff. Conclusions: The main achievement of the intensive international recruitment period from a UK viewpoint was that such a major undertaking was seen through without major disruption to NHS services. The wider costs and challenges meant, however, that large-scale international recruitment was not sustainable as a solution to workforce shortages. Should such approaches be attempted in future, a clearer upfront appraisal of all the potential costs and implications will be vital.

The information requirements of total purchasing projects: Implications for primary care groups

To successfully purchase, commission and manage health services at the primary care level requires accurate, reliable, up-to-date and appropriate information for use by trusts, health authorities, and by the soon to be operational primary care groups. The national total purchasing evaluation has provided evidence which will be relevant to primary care groups, particularly in the areas of information technology (IT) and access to information. Progress in developing independent purchasing by total purchasers was slower than anticipated because of the large number of factors which had to be taken into account, of which IT and information were just two. Accurate and timely information will be crucial for primary care groups if they are to move from level 1 to level 4 without undue delay.

Relationships between the key players in primary care groups and trusts ? some lessons from the total purchasing pilots

Primary care groups (PCGs) and primary care trusts (PCTs) are the way forward for primary care in the UK. These groups of general practitioners (GPs) and community nurses, organized along geographical lines, will need to forge relationships with other organizations and key players to a much greater extent than has been necessary hitherto. Currently PCGs most closely resemble the total purchasing pilots (TPPs), which have been the subject of a national evaluation. This paper reports on the evidence collected by interviewing key stakeholders ? lead GPs, health authority (HA) leads, project managers and social services representatives ? about how relationships developed in TPPs and how this might be relevant to PCGs and PCTs. The importance of good relationships with HAs was recognized by the TPPs, and the HAs were seen as having an important strategic role. Relationships with social services were slow to start for historical reasons, and had not progressed particularly far by the end of the study. Similarly, involving patients and the wider public in TPPs was problematic, and there was a lack of guidance about the most appropriate ways of proceeding. The evidence suggests that progress will be slow and the problems encountered by TPPs are likely to become apparent as PCGs develop, and with the transition to trust status. There is much for the primary care groups and trusts to learn from the TPPs