Anna Coleman

Primary health and social care services in the UK: Progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the states objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older peoples services.

Partnerships, performance and primary care: Developing integrated services for older people in England

The development of health services in England is currently shaped by three key factors: the active involvement of front-line health professionals (particularly family doctors – general practitioners) in decisions about resource allocation and service development priorities; the promotion of ‘partnerships’ between health and other organisations in order to deliver ‘joined-up’ services; and the close performance management of organisations and professionals to ensure that they meet externally prescribed objectives and targets. This paper considers the implications and impact of these factors on the development of services for older people. It discusses whether, under these circumstances, health service developments are likely to address some of the most pressing needs of older people.

Rethinking collegiality: Restratification in English general medical practice 2004–2008

For Freidson [(1985). The reorganisation of the medical profession. Medical Care Review, 42(1), 11-35], collegiality, or ostensible equal status amongst members of the medical profession, serves a dual purpose. It socialises members into an attitude of loyalty to colleagues and presents an image to those outside the profession that all its members are competent and trustworthy. However, Freidson saw the use of formal standards developed by one (knowledge) elite within medicine and enforced by another (administrative) elite as threatening collegiality and professional unity. Drawing on two studies in English primary medical care this paper reports the emergence of new strata or elites, with groups of doctors involved in surveillance of others and action to improve compliance in deficient individuals and organizations. Early indications are that these developments have not led to the consequences which Freidson predicted. The increasing acceptance of the legitimacy of professional scrutiny and accountability that we identify suggests that new norms are emerging in English primary medical care, the possibility of which Freidsons analysis fails to take account.

Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS.

Objective One of the key goals of the current reforms in the English National Health Service (NHS) under the Health and Social Care Act, 2012, is to increase the accountability of those responsible for commissioning care for patients (clinical commissioning groups (CCGs)), while at the same time allowing them a greater autonomy. This study was set out to explore CCGs developing accountability relationships. Design We carried out detailed case studies in eight CCGs, using interviews, observation and documentary analysis to explore their multiple accountabilities. Setting/participants We interviewed 91 people, including general practitioners, managers and governing body members in developing CCGs, and undertook 439 h of observation in a wide variety of meetings. Results CCGs are subject to a managerial, sanction-backed accountability to NHS England (the highest tier in the new organisational hierarchy), alongside a number of other external accountabilities to the public and to some of the other new organisations created by the reforms. In addition, unlike their predecessor commissioning organisations, they are subject to complex internal accountabilities to their members. Conclusions The accountability regime to which CCGs are subject to is considerably more complex than that which applied their predecessor organisations. It remains to be seen whether the twin aspirations of increased autonomy and increased accountability can be realised in practice. However, this early study raises some important issues and concerns, including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes.

The limits of market-based reforms in the NHS: the case of alternative providers in primary care

BackgroundHistorically, primary medical care in the UK has been delivered by general practitioners who are independent contractors, operating under a contract, which until 2004 was subject to little performance management. In keeping with the wider political impetus to introduce markets and competition into the NHS, reforms were introduced to allow new providers to bid for contracts to provide primary care services in England. These contracts known as ‘Alternative Provider Medical Services’, were encouraged by two centrally-driven rounds of procurement (2007/8 and 2008/9). This research investigated the commissioning and operation of such Alternative Providers of Primary Care (APPCs).MethodsTwo qualitative case studies were undertaken in purposively sampled English Primary Care Trusts (PCTs) and their associated APPCs over 14 months (2009-10). We observed 65 hours of meetings, conducted 23 interviews with PCT and practice staff, and gathered relevant associated documentation.Results and conclusionsWe found that the procurement and contracting process was costly and time-consuming. Extensive local consultation was undertaken, and there was considerable opposition in some areas. Many APPCs struggled to build up their patient list sizes, whilst over-performing on walk-in contracts. Contracting for APPCs was ‘transactional’, in marked contrast to the ‘relational’ contracting usually found in the NHS, with APPCs subject to tight performance management. These complicated and costly processes contrast to those experienced by traditionally owned GP partnerships. However, managers reported that the perception of competition had led existing practices to improve their services.The Coalition Government elected in 2010 is committed to ‘Any Qualified Provider’ of secondary care, and some commentators argue that this should also be applied to primary care. Our research suggests that, if this is to happen, a debate is needed about the operation of a market in primary care provision, including the trade-offs between transparent processes, fair procurement, performance assurance and cost.

Local histories and local sensemaking: a case of policy implementation in the English National Health Service

�Central policies that are only loosely specified might be expected to result in local variations in interpretation and implementation, and practice-based commissioning in the English National Health Service (NHS) is no exception. We show how local ‘sensemaking’ in relation to this policy has been influenced by local histories and by conceptual schemata derived from earlier reorganisations of the NHS. Changes to organisational formalities do not necessarily, therefore, result in reappraisals of sensemaking on the part of local actors. We also employ our data to address issues raised by commentators critical of the way the concept of sensemaking has been previously employed.

'We can't get anything done because ... ': making sense of 'barriers' to Practice-based Commissioning

Objectives: To investigate the issues raised by participants as ‘barriers’ to the development of Practice-based Commissioning (PBC) in ‘early adopter’ sites in England. Methods: Detailed case studies of five PBC consortia in three Primary Care Trusts (PCTs). Data collection included interviews with a wide range of respondents (46 in total), including general practitioners, PCT employees, Local Authority employees and patient representatives, observation of many different types of meetings (68 in total), and analysis of documents tabled at meetings and circulated at other times. Results: It has been claimed that progress in developing PBC has been slow. Our respondents articulated a number of factors that they felt were holding them back, which could have been identified as ‘barriers’ preventing change. The issues raised were consistent across our sites (lack of time, resources and personnel, and difficult relationships with the PCT), but observation suggested that these issues arose out of very different organizational ‘sensemaking’, and as a result the apparent ‘barriers’ had different meanings in different organizational contexts. Conclusion: Weicks concept of ‘organizational sensemaking’ provides a useful framework within which to explore the problems encountered when implementing policy. Observational methods are a powerful tool in understanding sensemaking. The variations in sensemaking that we observed suggest that the use of ‘barrier’ metaphors in descriptions of implementation problems risks homogenizing the portrayal of situations that differ greatly in reality. This implies that top-down or centrally driven solutions to such situations will often be inappropriate.

“Bridging the Gap”: New Relationships between Primary Care Groups and Local Authorities

Current policy places great emphasis on the development of “partnerships”, particularly between NHS and local authority services, with the aims of increasing service coordination and delivery and improving health. To this end, primary care groups (PCGs), at the forefront of NHS organizational developments, are required to include a social services representative on their governing boards; similarly, primary care trusts (PCTs) have a social services representative on their executive committees. Drawing on a representative longitudinal national survey of English PCGs, the paper evaluates the contribution of these new governance arrangements to the development of inter-agency partnerships. Despite poor histories of collaboration and some major organizational barriers, there are some signs of progress, with social services representatives playing an active part in PCG affairs and having clear lines of communication about PCG matters with their employing authorities. Equally significantly, PCGs have also quickly established a wide range of contacts directly with other local authority services and departments. However, these early gains risk being limited by traditional professional inequalities between social work and medicine and, in particular, by the prospect of further organizational upheaval as PCGs merge with each other and/or acquire trust status.

?Animateurs? and animation: what makes a good commissioning manager?

Objectives To examine the managerial behaviours adopted by commissioning managers in English primary care trusts (PCTs), and to explore the impact of these behaviours. Methods Qualitative case studies were undertaken in four PCTs, focusing on staff engaged in the commissioning of hospital services. Both formal and informal observation were undertaken (150 hours), and 41 in-depth interviews conducted with managers and general practitioners (GPs). Results Managers adopted many managerial behaviours familiar from the literature, including sharing information, and networking inside and outside the organization. Multiple organizational layers and unclear decisionmaking processes hindered this activity. In addition, some managers with responsibility for facilitating practice-based commissioning (PbC) adopted a managerial mode that we have called being an ‘animateur’. This approach involved the active management of disparate groups of people over whom the manager had no authority, and appeared to be a factor in determining success. It was facilitated by managerial autonomy and was more prevalent where managers were seen to have legitimacy. Some organizational practices appeared to inhibit its development. Conclusions From 2012/13 it is planned that GPs will be taking more responsibility for commissioning in the English NHS. This research suggests that managers of the new commissioning organizations will require a deep and contextualized understanding of the NHS and that it is important that organizational processes do not inhibit managerial behaviour. Legitimacy may be an issue in contexts were managers are automatically transferred from their existing appointments.

Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from Clinical Commissioning Groups and Shadow Health and Wellbeing Boards

Abstract Statutory responsibility for health care and social care has long been separated between National Health Service (NHS) bodies and local government authorities. Repeated policy attempts to promote service integration through collaboration between such authorities have achieved little. The latest of such policy interventions are the Health and Wellbeing Boards (HWBs) established by the 2012 Health and Social Care Act (HSCA) alongside a range of other organisational innovations, including Clinical Commissioning Groups (CCGs). These organisations await full legal and operational status but have begun to develop structures and processes. HWBs are intended to lead the integrated assessment of local needs to inform both NHS health and local authority social care commissioners. We undertook detailed qualitative case studies in eight CCGs during 2011–2012 and here report observational and interview data related to CCGs’ perspectives and observations of early HWB developments. We found that developing HWBs vary greatly in their structure and approach, but we also identified a number of significant issues that are familiar from earlier research into health and social care integration. These include heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.