Imelda McDermott

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.

?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.

Complexity in the new NHS: longitudinal case studies of CCGs in England.

Objective The reform in the English National Health Services (NHS) under the Health and Social Care Act 2012 is unlike previous NHS reorganisations. The establishment of clinical commissioning groups (CCGs) was intended to be ‘bottom up’ with no central blueprint. This paper sets out to offer evidence about how this process has played out in practice and examines the implications of the complexity and variation which emerged. Design Detailed case studies in CCGs across England, using interviews, observation and documentary analysis. Using realist framework, we unpacked the complexity of CCG structures. Setting/participants In phase 1 of the study (January 2011 to September 2012), we conducted 96 interviews, 439 h of observation in a wide variety of meetings, 2 online surveys and 38 follow-up telephone interviews. In phase 2 (April 2013 to March 2015), we conducted 42 interviews with general practitioners (GPs) and managers and observation of 48 different types of meetings. Results Our study has highlighted the complexity inherent in CCGs, arising out of the relatively permissive environment in which they developed. Not only are they very different from one another in size, but also in structure, functions between different bodies and the roles played by GPs. Conclusions The complexity and lack of uniformity of CCGs is important as it makes it difficult for those who must engage with CCGs to know who to approach at what level. This is of increasing importance as CCGs are moving towards greater integration across health and social care. Our study also suggests that there is little consensus as to what being a ‘membership’ organisation means and how it should operate. The lack of uniformity in CCG structure and lack of clarity over the meaning of ‘membership’ raises questions over accountability, which becomes of greater importance as CCG is taking over responsibility for primary care co-commissioning.

What happens when GPs engage in commissioning? Two decades of experience in the English NHS

Objective To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. Methods A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. Results The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with ‘virtuous cycles’ (experience of being able to make changes feeding back to encourage greater engagement) and ‘vicious cycles’ (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. Conclusion Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.

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.

Changing the Ties That Bind? The Emerging Roles and Identities of General Practitioners and Managers in the New Clinical Commissioning Groups in the English NHS

The English National Health Service (NHS) is undergoing significant reorganization following the 2012 Health and Social Care Act. Key to these changes is the shift of responsibility for commissioning services from Primary Care Trusts (PCTs) to general practitioners (GPs) working together in Clinical Commissioning Groups (CCGs). This article is based on an empirical study that examined the development of emerging CCGs in eight case studies across England between September 2011 and June 2012. The findings are based on interviews with GPs and managers, observations of meetings, and reading of related documents. Scott’s notion that institutions are constituted by three pillars—the regulative, normative, and cognitive–cultural—is explored here. This approach helps to understand the changing roles and identities of doctors and managers implicated by the present reforms. This article notes the far reaching changes in the regulative pillar and questions how these changes will affect the normative and cultural–cognitive pillars.

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.

Thinking about Case Studies in 3-D: Researching the NHS Clinical Commissioning Landscape in England

Abstract What is our unit of analysis and by implication what are the boundaries of our cases? This is a question we grapple with at the start of every new project. We observe that case studies are often referred to in an unreflective manner and are often conflated with geographical location. Neat units of analysis and clearly bounded cases usually do not reflect the messiness encountered during qualitative fieldwork. Others have puzzled over these questions. We briefly discuss work to problematise the use of households as units of analysis in the context of apartheid South Africa and then consider work of other anthropologists engaged in multi-site ethnography. We have found the notion of ‘following’ chains, paths and threads across sites to be particularly insightful. We present two examples from our work studying commissioning in the English National Health Service (NHS) to illustrate our struggles with case studies. The first is a study of Practice-based Commissioning groups and the second is a study of the early workings of Clinical Commissioning Groups. In both instances we show how ideas of what constituted our unit of analysis and the boundaries of our cases became less clear as our research progressed. We also discuss pressures we experienced to add more case studies to our projects. These examples illustrate the primacy for us of understanding interactions between place, local history and rapidly developing policy initiatives. Understanding cases in this way can be challenging in a context where research funders hold different views of what constitutes a case.