Nigel Charles

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.

‘Early days’: Knowledge and use of the Mental Capacity Act 2005 by care home managers and staff:

The Mental Capacity Act (MCA) was fully implemented in England and Wales in October 2007 and has relevance for the care home sector through its focus on decision-specific assessments of capacity. This article reports on research that forms part of a five year programme exploring evidence-based interventions in dementia and this article draws on part of the research that was designed to identify issues relating to implementation of the Act. Specific research questions for this study pertain to staff abilities to incorporate a new legal framework addressing mental capacity into care of people with dementia. Qualitative interviews with 32 staff in one group of care homes in Southern England demonstrated that, regardless of knowledge of MCA, the daily working ethos of staff appeared to be within the remit of Act. Training could therefore continue to build on these principles. However, considerable variation in understanding of terms and principles of the MCA was found. Few participants were aware of specific legislative points and offered ‘common sense’ explanations for their actions and decision-making. This level of knowledge may not meet regulators’ requirements or the needs of residents.

Estimates of the number of older people with a visual impairment in the UK

One of the key challenges to policy-makers and service providers charged with tackling social exclusion is knowing who and how many people their policies should be addressing. What is required are reliable estimates of the target population. This article considers two key studies that have made it possible to produce estimates of the size of the older visually impaired population in the UK. It concludes that there are between about 1.6m and 2.2m people aged 65 years and over in the UK with visual acuity ranging from mild to serious levels of visual impairment. About half of visually impaired older people fall into the category of mild vision impairment (6/12 — 6/18). The other half has a moderate to severe visual impairment (VA < 6/18). Women aged 65 years and over with moderate or severe visual impairment outnumber visually impaired men by nearly three to one. Of those aged 75 years and over with moderate to severe visual impairment, about half of them have cataracts or refractive error, many of whom could have treatment or intervention which would considerably improve their vision. There are also an estimated 300,000 people aged 75 years and over in the UK with registerable eye conditions.

Social care stakeholders' perceptions of the recruitment of international practitioners in the United Kingdom-a qualitative study

Mobility of labour is common within Europe and globally, particularly in social and health care. This article examines the findings from a qualitative study of 15 expert or stakeholder views that explored supply and demand factors in international social care staff recruitment to the United Kingdom (UK). Findings are that international social care workers have a better reputation and are perceived as being harder workers, more productive, more reliable, more focused and more likely to stay in a post longer than local workers. However, there is also the perception that employment in social care is a stepping-stone into other forms of employment both in the UK and when returning to home countries, through access to training, experience and improved job opportunities. The impact of migration policies on the composition of international workers is further noted because greater numbers of social care staff are coming to the UK from the European Union and fewer from Commonwealth states. Changes in the profile of international workers are discussed, with a need identified to address cultural and language differences to ensure good outcomes for service users.

An exploratory qualitative study of equity and the social care needs of visually impaired older people in England

This article describes the findings of a small study of the ways in which social care practitioners describe their assessment practice with visually impaired older people in England. The study interviewed 14 social care staff in three local authorities that had different organizational arrangements for assessments. Using a vignette method, the study explored staffs definitions of social care needs. Possible differences between the practice of specialists in visual impairment and those who were not working or trained specifically in the area of visual impairment are explored, as is the context of policy assessments for social care services. The potential impact of differences and context on equity is discussed.

Editorial -Special Issue on Social Inclusion and Visual Impairment

Tackling social exclusion and promoting social inclusion has been a major item on the current UK government’s social policy agenda. Increasing awareness that social exclusion has a major impact on people’s life chances has prompted a range of government projects and initiatives targeting crime, transport and employment (SEU, 2006). However, whilst these initiatives are to be commended, the causes of social exclusion and the mechanisms for promoting social inclusion are complex. Indeed, recent research has suggested that there is no single cause of social exclusion, rather that exclusion is multi-faceted and is a process of interrelated factors that, over time, produce people and places that are excluded from mainstream society (e.g. Webster, Simpson, MacDonald, Abbas, Creslik, Shildrick and Simpson, 2004). However, there is more to exclusion than the impact of complex social processes; as research and government policy has recognized, some people are more at risk than others (SEU, 2001).

Health and Social Care–Establishing a Joint Future?

cents’ (nine percent): young people admitted to care aged above eleven due to abuse or neglect. ‘Adolescent entrants’ (fourteen percent): young people first admitted to care aged eleven or over due to relationship breakdown at home. ‘Asylum seeking children’ (five percent) were mostly over age eleven. Three percent were ‘disabled children’. Nine percent of the children in the sample were adopted in the census year. Under half of those who started to be looked after left within a year. The chance of returning home for those who had been looked after for a year or more was very low. Many who went home did not stay there. Councils that returned home high proportions of children had higher number of children with repeat admissions. The authors used the definition of children ‘doing-well’ as including emotional well-being, behaviour, ‘positive adult ties’, being settled in current placement, getting on in education and ‘being safe and doing well’. In the authors’ view the challenge for councils is to aim to ‘increase the number of children who are with their families, adopted or in long term care and who can stay happily and safely where they are’. The case studies show clearly that the success in meeting this challenge depends on the relationships the children make. The most important of these are those the children make in the placements with their families, with adoptive parents or with foster carers. In the last chapter the authors offer many ‘implications for practice’. I highlight some of them: