AbstractThe 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.
Objective
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 documentary analysis 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 subject 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.
ConclusionCCGs are new organisations, faced with significant new responsibilities. This study provides early evidence of issues that CCGs and those responsible for CCG development may wish to address.
ObjectivesSince April 2015, Clinical Commissioning Groups (CCGs) have taken on the responsibility to commission primary care services. The aim of this paper is to analyse how CCGs have responded to this new responsibility and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems.DesignWe undertook an exploratory approach, combining data from interviews and national telephone surveys, with analysis of policy documents and case studies in four CCGs. Data were analysed using thematic content analysis.Setting/participantsWe reviewed 147 CCG application documents and conducted two national telephone surveys with CCGs (n=49 and n=21). We interviewed 6 senior policymakers and 42 CCG staff who were involved in primary care co-commissioning (general practitioners and managers). We observed 74 primary care commissioning committee meetings and their subgroups (approx. 111 hours).ResultsCCGs in our case studies focused their primary care commissioning activities on developing strategic plans, ‘new’ primary care initiatives, and dealing with legacy work. Many plans focused on incentivising and supporting practices to work together and provide a broad range of services. There was a clear focus on ensuring the sustainability of general practice. Our respondents expressed mixed views as to what new collaborative service models, such as the new models of care and sustainability and transformation partnerships (STPs), would mean for the future of primary care and the impact they could have on CCGs and their members.ConclusionsThere is a disconnect between locally based primary care and the wider system. One of the major challenges we identified is the lack of knowledge and expertise in the field of primary care at STP level. While primary care commissioning by CCGs seems to be supporting local collaborations between practices, there is some way to go before this is translated into broader integration initiatives across wider footprints.
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