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8 - The Changing Public Health System: an Examination of the new Commissioning Infrastructure
- Edited by Pauline Allen, University of Manchester, Kath Checkland, Valerie Moran, University of Kent, Canterbury, Stephen Peckham, Canterbury Christ Church University, Kent
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- Book:
- Commissioning Healthcare in England
- Published by:
- Bristol University Press
- Published online:
- 03 March 2021
- Print publication:
- 25 March 2020, pp 123-142
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- Chapter
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Summary
Introduction
The wide-ranging reforms made to health and care systems in England, as part of the HSCA 2012, created an enormous shakeup of the way the public health function is delivered. Key public health responsibilities were transferred from the NHS to local government councils. In addition, PHE was established as the national agency for public health.
This chapter examines what these changes have meant for the commissioning of services to improve population health. Commissioning in relation to the health improvement function refers to the strategic planning and purchasing of services that could include smoking cessation, weight management and drug and alcohol services, public health services for children and young people, comprehensive sexual health services and campaigns, dental public health services and services to prevent cancer and long-term conditions.
The political backdrop
The government's goal was to develop a ‘public health service that achieves excellent results, unleashing innovation and liberating professional leadership’ (Department of Health, 2010b). There were a number of important themes demonstrated in the structural changes. First, they represented an attempt to enhance democratic accountability and challenge the old ‘command and control’ model. Within the wider context of the localism agenda, the relocation of public health functions was an attempt to ensure that local people made local decisions to improve the health of local populations. Second, the government was attempting to shift the focus from processes onto outcomes. A comprehensive set of indicators were developed within a ‘public health outcomes framework’, against which local public health systems would be assessed. This would enable transparency and an element of comparability between different local areas. Third, there was an attempt to take a ‘different’ (though not new) approach to public health – one that takes a ‘life course’ perspective, and that places importance on wider determinants of health, particularly in relation to people's socioeconomic contexts. Fourth, there was a focus on ensuring that decisions are based on the best possible evidence of what works – a key role for PHE. Fifth, there was an emphasis on efficiency, particularly with regard to being ‘joined up’ and streamlined. And finally, consistent with wider policy, there was a general push towards commissioning, and lead organisations being solely commissioning organisations.
5 - Commissioning Primary Care Services: Concepts and Practice
- Edited by Pauline Allen, University of Manchester, Kath Checkland, Valerie Moran, University of Kent, Canterbury, Stephen Peckham, Canterbury Christ Church University, Kent
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- Book:
- Commissioning Healthcare in England
- Published by:
- Bristol University Press
- Published online:
- 03 March 2021
- Print publication:
- 25 March 2020, pp 63-82
-
- Chapter
- Export citation
-
Summary
Introduction
Under the HSCA 2012, NHSE was responsible for commissioning primary care services. However, in 2014 CCGs were invited to volunteer to take on responsibility for commissioning services from their member GP practices in addition to their wider responsibilities for commissioning acute and community services. This chapter draws upon research into the establishment of the ‘co-commissioning’ of primary care services by CCGs, which was conducted from April 2015 to April 2017 (McDermott et al, 2018). This chapter starts by exploring the history of primary care commissioning and financing in England and discusses the broad policy objectives which underpinned this significant change in CCGs’ role and scope. It examines whether and how the policy intention works in practice and explores factors affecting development of the policy, highlighting concerns over conflicts of interest, challenges in implementing the policy and unintended consequences. For clarity, the term ‘primary care commissioning’ is employed because this is the term used throughout the relevant policy documents. While globally the term ‘primary care’ often refers to the full range of out-of-hospital services, including community nursing and so on, in the UK, for the purposes of commissioning, a distinction is usually made between primary care (including GP services, and services provided by dentists and optometrists), secondary care (including standard hospital services), community care (including community nursing and a range of community-based services such as physiotherapy, occupational therapy and so on) and specialised care (including highcost, low-volume services). Following the HSCA 2012, CCGs were responsible for commissioning secondary and community care, whilst NHSE was responsible for primary and specialised care. In this book, references to primary care services predominantly mean primary medical care provided by GPs, as these are the services at which commissioning policy has been directed.
History of primary care commissioning and financing in England
The current primary care system in England is based on GPs being the contractors to the NHS rather than employees. This system was born out of the decision made at the establishment of the NHS in 1947 (Checkland et al, 2018b). This enabled GPs to remain independent of the NHS in a legal sense (although in reality the majority of practices depended overwhelmingly on NHS income), minimising their opposition to the NHS (Lewis, 1997; Peckham and Exworthy, 2003).
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