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4 - Clinical Engagement in Commissioning: Past and Present
- 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 49-62
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Summary
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 headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic. The Government will liberate the NHS from excessive bureaucratic and political control, and make it easier for professionals to do the right things for and with patients, to innovate and improve outcomes.
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.
3 - The Development and Early Operation of Clinical Commissioning Groups (CCGs)
- 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 35-48
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Summary
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.
2 - Context: Commissioning in the English NHS
- 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 15-34
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Summary
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.
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
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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).
eight - Clinically led commissioning: past, present and future?
- Edited by Mark Exworthy, University of Birmingham, Russell Mannion, University of Birmingham, Martin Powell
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- Book:
- Dismantling the NHS?
- Published by:
- Bristol University Press
- Published online:
- 05 April 2022
- Print publication:
- 28 July 2016, pp 149-170
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Summary
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:
Commissioning by GP consortia [now known as CCGs] will mean that the redesign of patient pathways and local services is always clinically led and based on more effective dialogue and partnership with hospital specialists. It will bring together responsibility for clinical decisions and for the financial consequences of these decisions (Department of Health, 2010, paragraph 4.4).
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.
Commissioning in the English National Health Service: What's the Problem?
- KATH CHECKLAND, STEPHEN HARRISON, STEPHANIE SNOW, IMELDA MCDERMOTT, ANNA COLEMAN
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- Journal:
- Journal of Social Policy / Volume 41 / Issue 3 / July 2012
- Published online by Cambridge University Press:
- 27 March 2012, pp. 533-550
- Print publication:
- July 2012
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- Article
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The English NHS is currently organised around a split between the ‘commissioning’ and the ‘providing’ of health care. There has been considerable critical comment about commissioning, focusing upon perceived inadequacies of the regulatory structure and a perceived lack of competence of the managers concerned. In this paper, we use empirical data from two detailed studies of commissioning to propose a third explanation of the difficulties that have been observed in making commissioning work. We apply Scott's institutional analysis to the issue, arguing that far from reflecting managerial incompetence, some of the difficulties experienced are inherent in the normative and cultural/cognitive pillars of the NHS institution, so that there is a lack of ‘fit’ between commissioning and the institutional characteristics of the NHS. We conclude by exploring the potential impact of the latest round of NHS changes on this institution.