The work of commissioning: a multisite case study of healthcare commissioning in England's NHS

Abstract

ObjectiveTo examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.DesignMultisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.ParticipantsPrimary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.SettingThree ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.ResultsCommissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.ConclusionsCommissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

“…Guidance recommends using multiple sources of evidence to construct cases, including outcomes data to demonstrate potential cost savings, academic research and national guidelines. 53,66,88 Existing recommendations have also highlighted the importance of developing effective co-operation and communication between the stakeholders involved. Developing a multidisciplinary working group led by a clinical lead has been advocated as a means of achieving this.…”

A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy

“…No studies of monitoring were identified. In relation to planning, there was a strong focus on the importance of comprehensive needs assessment for groups and populations Shaw et al 2013). Six studies addressed priority setting and rationing.…”

“…With respect to service use, Barnes et al (2013) found that in the context of inappropriate treatment of routine childhood (Baxter et al 2007; PCT case study); characteristics of commissioning managers (Checkland et al 2012; PCT); perceptions of value of priority-setting tools (decision support) for resource allocation (Marks et al 2011;PCTs); commissioning services for long-term conditions (Shaw et al 2013;PCTs); priority setting and rationing in PCTs (Robinson et al 2012; PCT case study); AFR framework to aid decision making (Bravo Vergel and Ferguson 2006;PCT); comparisons across commissioning models in Germany and UK (Sheaff et al 2013; PCT and other); views of CCG versus PCT commissioning (Turner et al 2013;PCT and CCG); are GPs best placed to deliver equity and excellence? Comparing GP commissioning with PCT (Gridley et al 2012; PCT and other); APMS contractual processes ; UK APMS); commissioning dental services through PDSS (Newton et al 2006; PDSS); barriers and enablers to commissioning ; PCT survey); engaging pharmacy in pharmaceutical needs assessment for commissioning pharmacy ; PCT) Quantitative: cluster RCT examining impact of commissioning on smoking cessation and entrance of new market players (McLeod et al 2015;PCTs); PBMA for purchasing (Wilson et al 2007; PCT) Mixed methods: redesigning children's services (Barnes et al 2013; PCT); use of external consultants by NHS commissioners (Naylor and Goodwin 2011; PCT interviews and survey); commissioners viewed HLP scheme as an effective model with which to deliver increased volume, quality and reliability of community health services (Kennington et al 2013; HLP) Fundholding practices (n = 1); PBC (n = 2); CCGs (n = 7) 1 quantitative; 9 qualitative 10 Quantitative: impact on cost containment and service use (Dusheiko et al 2006; fundholding) Qualitative: barriers to PBC (Checkland et al 2009; PBC); PBC as a service redesign tool (Slater and White 2007;PBC); investigating disinvestment practices (Rooshenas et al 2013;CCG); exploring development of CCG CCG); attitudes of GPs to commissioning including level of GP engagement with clinical commissioning and attitudes to incentives an...…”

“…Priority setting needs to be embedded in routine planning and budgeting processes (Robinson et al 2012a(Robinson et al , 2012b and provide support for disinvestment as well as investment decision making (Rooshenas et al 2013). Shaw et al (2013) found that commissioning care, especially longterm care, is time consuming and complex, and supported best by an incremental approach.…”

“…Integrated care involving primary and secondary care or health and social care is especially difficult to deliver in the context of competition and separation of purchaser and provider (Mannion 2008). Commissioning for long-term condition services requires competition and purchasing policy that allows commissioning to be undertaken in partnership with providers, blurring the distinction between commissioners and providers (Shaw et al 2013). Both providers and consumers need to be informed and have an opportunity to provide input into the commissioning process (Joyce 2015).…”