248 research outputs found
Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS
No full textObjective: 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 CCG’s developing accountability relationships.
Design: We carried out detailed case studies in eight CCGs, using interviews, observation and documentaryanalysis 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 responsible 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
Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England
No full textObjective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform. Design: The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents. Setting/participants: We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h). Results: Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs. Conclusions: Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating ‘network closure’ and calls into question the Government's intention to create a vibrant market of commissioning support provision
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
No full textThe 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
The changing public health system:an examination of the new commissioning infrastructure
No full textCommissioning Healthcare in England: Evidence, Policy and Practice
No full textThe aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene & Tropical Medicine, the University of Manchester and the University of Kent. PRUComm is funded by the Policy Research Programme of the English Department of Health and Social Care from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how NHS commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs.
The structural changes introduced by the Health and Social Care Act 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS.
There has been a great increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased and there has also been a proliferation of other NHS organisations required to regulate the complex system. The effect of this increase in complexity in the governance of the NHS has been wide-ranging. As a result, local
autonomy is severely limited and the original policy aspirations to deliver freedom from government control and greater accountability to patients and greater democratic legitimacy have not been realised to any significant degree.
In addition, the fragmentation of commissioning roles has been damaging to the planning and delivery of services which are subject to several commissioning regimes. Not only is there evidence of deterioration in patient outcomes, but the research has also demonstrated that significant effort, and thus opportunity cost, is required from commissioners to ‘knit back together’ pre-existing systems of service planning and delivery.
The issue of accountability of commissioners is closely related to the problem of increased complexity of commissioning and system governance. Local Clinical Commissioning Groups are stated to be membership organisations whose primary accountability is internally to their GP members. But in fact the strongest form of accountability would seem to be their hierarchical upwards accountability to NHS England, the national body running the NHS. In addition, the delegation of responsibility for commissioning of primary care to CCGs presents a risk that groups of GPs will commission themselves to provide services, creating a structural conflict of interest, which may undermine their public stewardship role in respect of commissioning budgets.
The complex regulatory structures of the NHS required to police the marketised system introduced by the HSCA 2012 have effects on the efficiency of the system as a whole. Inappropriate use of market institutional structures, as opposed to integrated hierarchies, can decrease overall efficiency by increasing costs of undertaking transactions.
A further effect of the changes to commissioning introduced by the HSCA 2012 has been on clinicians in primary care. Despite the fact that the research has indicated that they can make a useful contribution to commissioning by CCGs, the workload associated with such involvement is substantial, with a potentially damaging effect on the working lives of GPs, who are already under stress from excessive demands on their time. This makes the sustainability of the model of GP involvement in CCGs dubious.
Despite the problems associated with the HSCA 2012, we argue that there will always be a role for planning, and thus a degree of commissioning in the NHS, as a publicly funded system. Strategic decisions need to be made about the allocation of public resources between different services in order to optimise population health and wellbeing. It is also necessary to monitor the performance of providers of care and make improvements where care is substandard. Thus, the core activities of commissioning are necessary whether pro-competitive quasi-market aspects of the English NHS are retained or not. But commissioning in its current form is unlikely to continue, given plans being developed at national level merge CCGs and introduce intermediate tiers of supervision
The changing public health system:an examination of the new commissioning infrastructure
No full textThe changing public health system:an examination of the new commissioning infrastructure
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