What happens when GPs engage in commissioning? Two decades of experience in the English NHS

Exploring whether primary care networks can contribute to the national goal of reducing health inequalities: a mixed-methods study

BACKGROUND

Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities.

AIM

To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities.

DESIGN AND SETTING

A sequential mixed-methods study of PCNs in England.

METHOD

Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019-2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020-March 2022).

RESULTS

Across 1243 networks in 2019-2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022-2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally.

CONCLUSION

Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.

'It is still coming from the centre and coming out': The material conditions adding to over-bureaucratised patient and public involvement for commissioning health and care in England

OBJECTIVE

To understand how materiality affects patient and public involvement (PPI) for commissioning and leading health and care services in the English National Health Service (NHS) context.

CONTEXT

From April 2013 groups of general practitioners (GPs) became members of NHS clinical commissioning groups (CCGs) to assess needs and procure core health services for and with local communities. Since July 2022, integrated care systems (ICSs) have subsumed this responsibility. NHS reorganisations have been driven by the promise of more effective and efficient health care and have led to a long history of PPI on economic, political, and moral grounds. Few studies researching PPI in clinical commissioning exist and fewer still have explored a more agentic understanding of materiality and its impact on PPI.

STUDY DESIGN

A focused ethnography was used to examine PPI for clinical commissioning within two CCG case study sites in England. Three CCG Governing Body lay representatives, nine GP commissioners and seven service user representatives took part in focus groups and/or were interviewed. Fifteen nonparticipant observations were also carried out at CCG meetings and the associated materiality was examined.

FINDINGS

The materiality of activities involved in clinical commissioning influences and shapes the nature of PPI. These forms of materiality may dilute and subvert meaningful engagement and involvement that relies on trust, leadership, learning, and partnership working.

CONCLUSION

System leaders in ICSs should consider the significance of materiality in centrally driven processes involved in PPI commissioning to reduce barriers and ensure meaningful partnerships within local communities.

PATIENT AND PUBLIC CONTRIBUTION

The study design ensured PPI throughout the research process in keeping with contemporary research practice guidance. The project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings.

The usage of data in NHS primary care commissioning: a realist review

BACKGROUND

Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data.

METHODS

We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory.

RESULTS

Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data.

CONCLUSIONS

There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.

The impacts of GP federations in England on practices and on health and social care interfaces: four case studies

Background

General practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form.

Objectives

The aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders.

Design

This was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis.

Results

All federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims. We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the requirements to provide additional services as part of NHS Improving Access to General Practice policy in a way that would not have been possible in the absence of federations. However, this added to pressures faced by busy clinicians and managers.

Limitations

The focus was on only four sites; therefore, any federations that were more active than those federations in these four sites will have been excluded. In addition, although patients were interviewed, because most were unaware of federations, they generally had little to say on the subject.

Conclusions

General practices working collaboratively can produce benefits, but this takes time and effort. The approach of the federation central authority (authoritative, indulgent or neglectful) was hugely influential in affecting processes and outcomes. However, progress was generally slower than anticipated, and negligible in one case.

Future work

Future work would benefit from multimethod designs, which provide in-depth, longitudinal, qualitative and quantitative methods, to shed light on processes and impacts.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

Coordinating primary care services: A case of policy layering

In this paper, we discuss the processes of policy layering as they relate to health care reform. We focus on efforts to achieve systems of coordinated primary care, and demonstrate that material change can be achieved through processes of incremental policy layering. Such processes also have a high potential for unintended consequences. Thus, we propose new principles of 'smart' policy layering to guide decision-makers to do incrementalism better. We then apply these principles to recent primary care reforms in Ontario, Canada. This paper conceptualizes 'smart' policy layering as a mechanism to achieve productive policy change in contexts with strong institutional barriers to reform.

Lessons for 'large-scale' general practice provider organisations in England from other inter-organisational healthcare collaborations

Policymakers in England are increasingly encouraging the formation of 'large-scale' general practice provider collaborations with the expectation that this will help deliver better quality services and generate economies of scale. However, solid evidence that these expectations will be met is limited. This paper reviews evidence from other inter-organisational healthcare collaborations with similarities in their development or anticipated impact to identify lessons. Medline. SSCI, Embase and HMIC database searches identified a range of initiatives which could provide transferable evidence. Iterative searching was undertaken to identify further relevant evidence. Thematic analysis was used to identify areas to consider in the development of large-scale general practice providers. Framework analysis was used to identify challenges which may affect the ability of such providers to achieve their anticipated impact. A narrative approach was used to synthesise the evidence. Trade-offs exist in 'scaling-up' between mandated and voluntary collaboration; networks versus single organisations; small versus large collaborations; and different types of governance structures in terms of sustainability and performance. While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size. Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.

The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review

BACKGROUND

Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant.

AIM

To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England.

DESIGN AND SETTING

Systematic review.

METHOD

Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England.

RESULTS

A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care.

CONCLUSION

Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.

General practitioners' views of clinically led commissioning: cross-sectional survey in England

OBJECTIVES

Involving general practitioners (GPs) in the commissioning/purchasing of services has been an important element in English health policy for many years. The Health and Social Care Act 2012 handed responsibility for commissioning of the majority of care for local populations to GP-led Clinical Commissioning Groups (CCGs). In this paper, we explore GP attitudes to involvement in commissioning and future intentions for engagement.

DESIGN AND SETTING

Survey of a random sample of GPs across England in 2015.

METHOD

The Eighth National GP Worklife Survey was distributed to GPs in spring 2015. Responses were received from 2611 respondents (response rate = 46%). We compared responses across different GP characteristics and conducted two sample tests of proportions to identify statistically significant differences in responses across groups. We also used multivariate logistic regression to identify the characteristics associated with wanting a formal CCG role in the future.

RESULTS

While GPs generally agree that they can add value to aspects of commissioning, only a minority feel that this is an important part of their role. Many current leaders intend to quit in the next 5 years, and there is limited appetite among those not currently in a formal role to take up such a role in the future. CCGs were set up as 'membership organisations' but only a minority of respondents reported feeling that they had 'ownership' of their local CCG and these were often GPs with formal CCG roles. However, respondents generally agree that the CCG has a legitimate role in influencing the work that they do.

CONCLUSION

CCGs need to engage in active succession planning to find the next generation of GP leaders. GPs believe that CCGs have a legitimate role in influencing their work, suggesting that there may be scope for CCGs to involve GPs more fully in roles short of formal leadership.

Multi-stakeholder perspectives of locally commissioned enhanced optometric services

OBJECTIVES

To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services.

DESIGN

Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups).

SETTING

A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists.

PARTICIPANTS

189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners.

RESULTS

Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently.

CONCLUSIONS

Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

Objectives To explore the 'added value' that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives. Methods Realist evaluation. We identified the programme theories underlying the claims made about GP 'added value' in commissioning from interviews with key informants. We tested these theories against observational data from four case study sites to explore whether and how these claims were borne out in practice. Results The complexity of CCG structures means CCGs are quite different from one another with different distributions of responsibilities between the various committees. This makes it difficult to compare CCGs with one another. Greater GP involvement was important but it was not clear where and how GPs could add most value. We identified some of the mechanisms and conditions which enable CCGs to maximize the 'added value' that GPs bring to commissioning. Conclusion To maximize the value of clinical input, CCGs need to invest time and effort in preparing those involved, ensuring that they systematically gather evidence about service gaps and problems from their members, and engaging members in debate about the future shape of services.

Redesign and commissioning of sexual health services in England - a qualitative study

OBJECTIVES

Responsibility for the commissioning of sexual and reproductive health (SRH) services transferred from the National Health Service to local authorities in England in 2013. This transfer prompted many local authorities to undertake new procurements of these SRH services. This study was undertaken to capture some of the lessons learnt in order to inform future commissioning and system redesign.

STUDY DESIGN

A qualitative study was carried out involving semi-structured interviews.

METHODS

Interviews were conducted with 13 local authority sexual health commissioners in Yorkshire and the Humber from 11 interviews. Thematic analysis was used to identify themes from transcripts of the interviews with the 13 participants.

RESULTS

Key themes identified were as follows: the challenge and complexity to those new to clinical commissioning; the prerequisites of robust infrastructural inputs to undertake the process, including technical expertise, a dependable project team, with clarity over the timescales and the budget; the requirement for good governance, stakeholder engagement and successful management of relationships with the latter; and the need to focus on the outcomes, aiming for value for money and improved system performance.

CONCLUSIONS

Several key issues emerged from our study that significantly influenced the outcome of the redesign and commissioning process for sexual health services. An adapted model of the Donabedian evaluation framework was developed to provide a tool to inform future system redesign. Our model helps identify the key determinants for successful redesign in this context which is essential to both mitigate potential risks and maximize the likelihood of successful outcomes. Our model may have wider applications.

Do marginal investments made by NHS healthcare commissioners in the UK produce the outcomes they hope to achieve? Observational study

OBJECTIVE

To investigate the effect of targeted marginal annual investments by local healthcare commissioners on the outcomes they expected to achieve with these investments.

DESIGN

Controlled before and after study.

SETTING

152 commissioning organisations (primary care trusts) in England.

METHODS

National surveys of commissioning managers in 2009 and 2010 to identify: the largest marginal investments made in four key conditions/services (diabetes, coronary heart disease, chronic pulmonary airways disease and emergency and urgent care) in 2008/2009 and 2009/2010; the outcomes commissioners expected to achieve with these investments; and the processes commissioners used to develop these investments. Collation of routinely available data on outcomes commissioners expected from these investments over the period 2007/2008 to 2010/2011.

RESULTS

51% (77/152) of commissioners agreed to participate in the survey in 2009 and 60% (91/152) in 2010. Around half reported targeted marginal investments in each condition/service each year. Routine data on many of the outcomes they expected to achieve through these investments were not available. Also, commissioners expected some outcomes to be achieved beyond the time scale of our study. Therefore, only a limited number of outcomes of investments were tested. Outcomes included directly standardised emergency admission rates for the four conditions/services, and the percentage of patients with diabetes with glycated haemoglobin <7. There was no evidence that targeted marginal investments reduced emergency admission rates. There was evidence of an improvement in blood glucose management for diabetes for commissioners investing to improve diabetes care but this was compromised by a change in how the outcome was measured in different years. This investment was unlikely to be cost-effective.

CONCLUSIONS

Commissioners made marginal investments in specific health conditions and services with the aim of improving a wide range of outcomes. There was little evidence of impact on the limited number of outcomes measured.