Introduction

The National Health Service (NHS) has a key role in improving population health in Britain. Yet despite progress, health inequalities persist (PHE, 2018a), as noted in Chapters 1 and 2. Life expectancy has increased for some groups, including those living with complex, multiple and chronic conditions, but others have experienced a widening of the inequality gap (Raleigh, 2018); see Chapters 1 and 2 for a social determinants perspective on health inequalities. The demographic shift towards an ageing and growing population places new demands on the health care system, raising questions about its long-term sustainability (Guzman-Castillo et al, 2017). Successive governments have pursued centralisation, delegation, devolution and privatisation as means of addressing growing demands across the health and social care system (Peckham et al, 2005). Recently, in England, a clear consensus has emerged to embed (public) health in all policies (HiAP), taking into account wider determinants of health and including prevention (LGA, 2016). Local Authorities (LAs) are seen to be uniquely positioned to facilitate this transformation, being close to local communities with an understanding and responsibility for issues such as environment, employment, housing and education. These socio-economic factors are seen to significantly impact on people's health and wellbeing in a way that the NHS cannot address alone. The NHS Long Term Plan (NHSE, 2019) and the earlier ‘Prevention is Better than Cure’ document (DHSC, 2018) set out the government's ambition to reshape the existing health care model by strengthening public health and prioritising primary medical and community health services. Central to this are Integrated Care Systems (ICSs), planned to be in place across the whole of England by April 2021, which provide a stronger basis from which the NHS, LAs and other organisations can work together on prevention, wellbeing and health. However, on average, local government spending on services has fallen by 21 percent in real terms since 2009–10 and these cuts have not been equally distributed across the country, being greater in more deprived areas (Amin-Smith and Phillips, 2019, p 2).

Against this backdrop, this chapter offers a critical analysis of the role of LAs in relation to promoting health and wellbeing for local communities.

Introduction

As discussed in Chapters 1 and 2, one of the central tenets of the HSCA 2012 was the desirability of increasing the involvement of GPs (and other clinicians) in the commissioning of services for their patients. This ideological commitment – based upon belief and founded, in part at least, upon an implicit denigration of managerial work (in order to increase control over the NHS and commissioners), had far-reaching consequences in the design of the reforms. For example, the initial separation of responsibility for commissioning primary care services from secondary and community services was deemed necessary because of the potential for conflicts of interest, whilst the creation of CCGs as ‘membership organisations’ had, as seen in Chapter 3, significant implications for their organisation and governance. The initial White Paper, ‘Equity and Excellence’ (Department of Health, 2010a: 9) was relatively non-specific about the expected benefits of clinical leadership of commissioning. It was argued that:

The document suggested that the proposals would: ‘liberate professionals and providers from top down control’; shift decision making closer to patients; enable better dialogue between primary and secondary care practitioners; and ensure that service development had real clinical involvement. However, the mechanisms underlying these perceived benefits were unstated. Furthermore, it was claimed that, whilst previous incarnations of GP-led commissioning (which in the UK go back to the creation of ‘GP fundholding’ in the 1990s) had delivered some benefits, these had been limited by the failure to give those involved complete autonomy and real budgets. The creation of CCGs, it was argued, would remedy these problems and ‘liberate’ clinicians to significantly improve care.

Introduction

The changes introduced by the HSCA 2012 represented a substantial redistribution of responsibilities within the English NHS. This included the compulsory membership of CCGs for GPs, via their practices, which was linked to a quality payment, defined locally by the CCG, for those successfully carrying out commissioning responsibilities. The policy was intentionally permissive when first introduced, with, for example, the size and composition of CCGs not imposed. In a letter to GPs in September 2010, Sir David Nicholson, Chief Executive of NHSE stated that: ‘We would want to enable new organisations, and particularly [CCGs], to have the maximum possible choice of how they operate and who works for them. It is important that GP practices be given time and space to develop their plans to form commissioning consortia’ (Nicholson, 2010). During October 2010, groups of GPs were invited to join aspiring CCGs, with the help of local SHAs – organisations that led the strategic development of the local health service and managed PCTs and NHS Trusts (NHS Digital, 2018) – to begin to organise themselves. By June 2011, there was over 90 per cent coverage of CCGs in England. Over time the policy became more constrained, with recommendations made for CCGs not to cross LA boundaries, optimal population coverage being suggested, and maximum management budgets being set. In supporting GP practices towards CCG establishment, NHSE published guidance setting out what should be considered when putting in place the necessary arrangements (NHS Commissioning Board, 2012c). The key elements of the guidance included:

• • The need to have a defined geographical footprint in order to commission for populations not registered with a GP practice.

• • The need for CCGs to be established as ‘membership organisations’, with GP practices as members, collectively making decisions about how the CCG should be set up and function.

• • The issues to be addressed in a constitution, including: arrangements to ensure transparency; provision to hold meetings in public; appointing an audit and a remuneration committee; arrangements for relevant subcommittees if required.

• • Safeguards against conflicts of interest.

• • The key issues to be considered in appointing GB members, including the appointment of lay membership along with a hospital consultant and a nurse from outside the CCG's geographical area.

Introduction

This chapter provides a brief contextual summary, setting out the organisation and governance of commissioning in the NHS. It gives an overview of commissioning from the creation of the internal market in the late 1980s to its consolidation pre-and post-HSCA 2012, and highlights the important changes which were brought about by the HSCA 2012. The chapter highlights the programme theories underlying the internal market and the HSCA 2012, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning. The architecture of commissioning following the HSCA 2012 is outlined and an overview of developments since the Act is presented.

It is perhaps important to note here that clinical involvement in commissioning has been variously referred to as ‘clinically-led’ and ‘GP-led’. In its earliest manifestations (GP fundholding) there was a clear policy commitment to the involvement of local GPs (primary care physicians) in commissioning. As noted in Chapter 1 this policy was driven by a belief in the value of local clinical knowledge, rather than by any evidence of its value. Over time, emphasis in policy has shifted between ‘GP-led commissioning’ (such as fundholding, PBC) and ‘clinically led commissioning’ (such as Primary Care Groups [PCGs]). The use of the wider term ‘clinically led’ has been used by policy makers to signal a commitment to the wider engagement of other clinicians such as nurses and hospital consultants, often in response to representations from other professional groups. Thus, in their first iteration, CCGs were explicitly intended to be GP-focused, but during a consultation period the rules were amended to mandate the involvement of both a nurse and a hospital consultant on CCG governing bodies, and policy documents reflected this by referring to ‘clinically led’ commissioning. However, in practice, clinically led commissioning has generally meant GP-led commissioning, with the involvement of other clinicians tokenistic at best. In this book, for consistency, the term ‘GP-led commissioning’ is used, but acknowledge that policy has, at times, tried to promote a wider clinical engagement beyond local GPs.

Internal market/purchaser– provider split – the origins of ‘commissioning’

The NHS was established initially in 1948 as a hierarchical public Organisation.

Introduction

Competition and cooperation are the two fundamental mechanisms of service procurement in the NHS and represent the tools for ‘getting things done’. This chapter presents empirical findings from a longitudinal, qualitative case study research project into the use of competition and cooperation by local NHS commissioners following the HSCA 2012.

As outlined in Chapter 2, the economics of markets (and their opposite, hierarchies) in conjunction with more sophisticated theories of cooperation underpin the analysis of competition and cooperation in the NHS quasi-market. For a market to operate competitively, there needs to be sufficient numbers of buyers and sellers of goods and services. A key assumption is that purchasers have sufficient information about the goods or services to make rational choices and maximise their utility. The market will produce value for money by allocating resources to the best use at the most efficient price (Allen, 2013).

Competition in the NHS is realised through several models. Competition for the market is a result of tendering processes whereby different providers compete to deliver a particular service and one provider wins the whole market. Competition within the market exists when a number of providers are accredited to provide a particular service and they compete to attract patients. An example of the competition for the market is tendering out of community health services, and an example of competition within the market is the patient choice of elective secondary or community-based care.

In order to analyse cooperation the theory of ‘co-opetition’ and the work of Elinor Ostrom (2005) are utilised. Co-opetition suggests that organisations can compete and cooperate simultaneously to mutual benefit (Brandenburger and Nalebuff, 1996). Ostrom suggests that individuals can self-organise to solve collective problems, without direct control by the government, and can establish and enforce rules limiting the appropriation of common pool resources.

In terms of defining cooperation, there are a number of closely related terms such as collaboration, coordination, integrated care, networking and partnership. Integrated care implies the coordination of separate but interconnected components which should function together to perform a shared task (Kodner and Spreeuwenberg, 2002).

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.

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).

Introduction

One of the key elements of the Health and Social Care Act 2012 (HSCA 2012) was the transfer of responsibility for commissioning healthcare services from managerially led Primary Care Trusts (PCTs) to newly established Clinical Commissioning Groups (CCGs), led by General Practitioners (family doctors or primary care physicians, generally known as GPs). The 2010 White paper, ‘Equity and Excellence’ argued that:

The document goes on to acknowledge that this approach is not wholly new, arguing that, ‘commissioning never became a real transfer of responsibility. So we will learn from the past, and offer a clear way forward for GP consortia’ (Department of Health, 2010, paragraph 4.5).

In this chapter we examine that history, and explore what can be learnt from previous attempts to involve GPs in commissioning care. We will then apply that learning to the provisions of the HSCA 2012, highlighting the correspondences and discontinuities between what we know from history and what was proposed. We will then go on to present evidence from our research on CCGs, exploring what happened in practice when CCGs were established. Finally, we will discuss the continuing evolution of health policy in the UK in the light of both historical evidence and our current findings. Throughout this chapter, the focus is upon GP involvement in commissioning, rather than the wider concern of clinician involvement. This is because the explicit goal of the HSCA 2012 was to bring GPs back into the forefront of commissioning.

Clinically led commissioning: a brief history

This and the subsequent section draw on a comprehensive literature review carried out between 2011 and 2014 (Miller et al, 2012; Miller et al, 2015), where all the relevant references can be found. Clinical involvement in the commissioning of healthcare services started with the introduction of the quasi-market into the NHS in 1991. The function of purchasing services was separated out from their provision, with Health Authorities established as purchasing bodies, responsible for assessing population needs and purchasing care from semiautonomous NHS Trusts.

Introduction

Health and Wellbeing Boards (HWBs) emerged from debates about the Health and Social Care Bill (2011) as a key coordinating mechanism or steward for local health and social care systems (House of Commons Communities and Local Government Committee, 2013, 14). For many this is yet a further attempt to improve coordination between health and social care services which historically has been a mixed experience (Lewis, 2001; Glendinning and Means, 2004; see chapter 9). The rationale for HWBs, however, includes a broader coordinating function across local authority (LA) services with a role in addressing the wider social determinants of health such as housing, education and planning, as well as social care (see Chapter 10). This wider context of joint-working is generally unexplored despite the emergence in some areas of joint public health directors pre-dating the formal shift of Primary Care Trust public health responsibilities to local government in 2013 (Marks et al, 2011).

While partnerships are seen to be a prerequisite for tackling ‘wicked issues’ (issues so complex that their solution lies with a multi-agency response), historically they seem unable to break free from the ‘silobased’ structures which govern how many UK public services are organised and delivered (Coleman, 2014). Past initiatives to achieve joined up, well coordinated and jointly planned services have previously had limited success.

Various approaches to local authority and NHS partnerships have been introduced since the 1970s with varied success (Hunter and Perkins, 2014). Funding structures remained a key barrier partially addressed by the 1999 Health Act which introduced new ‘flexibilities’ allowing health bodies and LAs to

• • set up pooled budgets

• • delegate function, by nominating a lead commissioner or integrating provision, and

• • transfer funds between bodies.

The aim was that services should become far more coordinated, designed around users and potentially a cost saving. For example, keeping an elderly person in hospital can be more expensive than the more appropriate package of social care needed to allow the patient to be discharged. With pooled budgets, funds would no longer be tagged as belonging to health or social services, and managers would be able to take more sensible, holistic decisions; however, issues remained, such as non-compatibility of budgetary cycles, audit and governance arrangements and non-coterminous boundaries.