Lynsey Warwick-Giles

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.

How Clinical Commissioning Groups Tackle Health Inequalities: A Qualitative Case Study

This PhD project aimed to explore how newly forming Clinical Commissioning Groups were tackling health inequalities (if at all) in the United Kingdom. In 2010, the current coalition government was formed between the Conservatives and Liberal Democrats. Policy developments led to a change in the organisational structure of the National Health Service, whereby Clinical Commissioning Groups were introduced and charged with a duty to tackle health inequalities. Health inequalities are frequently referred to within politics, health and research. The complexity of the concept and differences in peoples understandings of the term meant that a fundamental element of this project was to explore how individuals and organisations conceptualised health inequalities and how this influenced their approach to tackling the issue. Three Clinical Commissioning Groups in the North of England were recruited, and a qualitative case study was conducted. Research methods included interviews, observations and document analysis. Data were collected over a period of 11 months from January 2012 to December 2012. Health inequalities were found to be conceptualised and tackled differently across the three Clinical Commissioning Groups. There were several common themes that were important to Clinical Commissioning Group (CCG) members when describing their understandings of health inequalities and strategies to tackle the issue. These included history, relationships and the role of Public Health.

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.