Donna Bramwell

How can GPs and community health services work more effectively together

On 23 October 2014, NHS England Chief Executive Simon Stevens published a new 5-year plan for the NHS. Highlighting the challenges facing the NHS associated with an ageing population, the document argues: ‘The traditional divide between primary care, community services, and hospitals — largely unaltered since the birth of the NHS — is increasingly a barrier to the personalised and coordinated health services patients need .’1 It then goes on to discuss what models of care might look like under the plan. The focus is on integration and collaboration, eschewing further structural change but highlighting the potential of new service models which bring GPs together with a wide range of other providers, including community, social, and acute care services. Moving care closer to patients’ homes is highlighted, with vulnerable patients cared for proactively by multidisciplinary teams. None of this is new. GP fundholders pioneered better access to diagnostic tests and outreach by hospital consultants in the 1990s,2 while the 2000s brought Community Matrons, Virtual Wards, and Models of Case Management.3 However, integration between primary and community health services (CHS) has not been easy to achieve,4 and it is far from clear that such service models can, in fact, reduce costs.5 Against this background, an extensive review of existing literature was conducted to explore what factors should be taken into account in planning for primary care and CHS to work more effectively together. Starting with interdisciplinary healthcare teamworking (the micro-level), evidence was examined across all levels of the current care system to account for the diversity of the services. At the meso level (that is, …

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

High-quality primary care services are an essential part of a successful health service. However, the planning and management of such services is complex. Using evidence from a study of recent extensive changes in the English NHS, the authors highlight the need for local service oversight by managers who understand local conditions and needs. The recent English experience supports an incremental policy adjustment approach, rather than wholesale organizational change.

Views of public health leaders in English local authorities – changing perspectives following the transfer of responsibilities from the National Health Service to local government

ABSTRACT This paper reports on the findings of a research project that examined the changes to the public health system in England introduced in 2013. Drawing on case study research and two national surveys the findings explore the impact of organisational change on the composition and role of public health teams. Views and experiences were obtained from public health leaders involved in the transfer of staff and functions from the National Health Service in England to local authorities. National surveys at two points in time aimed to compare and contrast views on the evolving changes. The new organisational and managerial arrangements had enabled public health professionals to widen their work and influence, and public health skills and budgets were welcomed by those in local government. Initially, in some areas, directors of public health were less certain of the benefits of the transfer to local government compared to high levels of confidence expressed by elected members, but perspectives changed over time and moved closer together. National headline figures were found to mask high levels of turbulence and churn being experienced by individual authorities identified in the case study research, and the trend of reducing capacity through cuts to staff, budget and services was a cause for serious concern.

A case of tightrope walking: An exploration of the role of employers and managers in supporting people with long-term conditions in the workplace

Purpose – Given that current policy in the UK is focused on encouraging individuals with long-term health conditions (LTCs) to work wherever possible, the purpose of this paper is to explore employer’s and manager’s perspectives of supporting those with LTCs as any successful workplace engagement will largely be influenced by their readiness to be supportive. Design/methodology/approach – In total, 40 semi-structured in-depth interviews were conducted with employers’ and managers’ from a range of organisations in the north-west of England during the period March 2011 to January 2012. Comparative analysis of the data was guided and informed by grounded theory principles. Findings – All bar one participant typified their role as one of a difficult “balancing” act of additional and often incompatible demands, pressures and feelings. It was evident that coping with this ambivalent situation incurred an emotional consequence for participants. Practical implications – Employers’ and managers’ response to ambiva...

Beyond the parish pump: what next for public health?

BackgroundPublic health has had a history characterised by uncertainty of purpose, locus of control, and workforce identity. In many health systems, the public health function is fragmented, isolated and under-resourced. We use the most recent major reforms to the English National Health Service and local government, the Health and Social Care Act 2012 (HSCA12), as a lens through which to explore the changing nature of public health professionalism.MethodsThis paper is based upon a 3-year longitudinal study into the impacts of the HSCA12 upon the commissioning system in England, in which we conducted 141 interviews with 118 commissioners and senior staff from a variety of health service commissioner and provider organisations, local government, and the third sector. For the present paper, we developed a subset of data relevant to public health, and analysed it using a framework derived from the literature on public health professionalism, exploring themes identified from relevant policy documents and research.ResultsThe move of public health responsibilities into local government introduced an element of politicisation which challenged public health professional autonomy. There were mixed feelings about the status of public health as a specialist profession. The creation of a national public health organisation helped raise the profile of profession, but there were concerns about clarity of responsibilities, accountability, and upholding ‘pure’ public health professional values. There was confusion about the remit of other organisations in relation to public health.ConclusionsWhere public health professionals sit in a health system in absolute terms is less important than their ability to develop relationships, negotiate their roles, and provide expert public health influence across that system. A conflation between ‘population health’ and ‘public health’ fosters unrealistic expectations of the profession. Public health may be best placed to provide leadership for other stakeholders and professional groups working towards improving health outcomes of their defined populations, but there remains a need to clarify the role(s) that public health as a specialist profession has to play in helping to fulfil population health goals.

How are clinical commissioning groups managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis.

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.