The limits of market-based reforms in the NHS: the case of alternative providers in primary care

BACKGROUND: Historically, primary medical care in the UK has been delivered by general practitioners who are independent contractors, operating under a contract, which until 2004 was subject to little performance management. In keeping with the wider political impetus to introduce markets and competition into the NHS, reforms were introduced to allow new providers to bid for contracts to provide primary care services in England. These contracts known as ‘Alternative Provider Medical Services’, were encouraged by two centrally-driven rounds of procurement (2007/8 and 2008/9). This research investigated the commissioning and operation of such Alternative Providers of Primary Care (APPCs). METHODS: Two qualitative case studies were undertaken in purposively sampled English Primary Care Trusts (PCTs) and their associated APPCs over 14 months (2009-10). We observed 65 hours of meetings, conducted 23 interviews with PCT and practice staff, and gathered relevant associated documentation. RESULTS AND CONCLUSIONS: We found that the procurement and contracting process was costly and time-consuming. Extensive local consultation was undertaken, and there was considerable opposition in some areas. Many APPCs struggled to build up their patient list sizes, whilst over-performing on walk-in contracts. Contracting for APPCs was ‘transactional’, in marked contrast to the ‘relational’ contracting usually found in the NHS, with APPCs subject to tight performance management. These complicated and costly processes contrast to those experienced by traditionally owned GP partnerships. However, managers reported that the perception of competition had led existing practices to improve their services. The Coalition Government elected in 2010 is committed to ‘Any Qualified Provider’ of secondary care, and some commentators argue that this should also be applied to primary care. Our research suggests that, if this is to happen, a debate is needed about the operation of a market in primary care provision, including the trade-offs between transparent processes, fair procurement, performance assurance and cost

Community Nursing Services in England

This open access book provides an historical account of the ways in which community nursing services in England have been shaped by policy changes, from the inception of the NHS in 1948 to the present day. Focusing on policies regarding the organisation and provision of community nursing services, it offers an important assessment of how community nursing has evolved under successive governments. The book also provides reflections on how historic policies have influenced the service of today, and how lessons learnt from the past can inform organisation and delivery of current and future community nursing services. It is an important resource for those researching community nursing and health services, as well as practitioners and policy makers

Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England

Objective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform. Design: The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents. Setting/participants: We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h). Results: Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs. Conclusions: Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating ‘network closure’ and calls into question the Government's intention to create a vibrant market of commissioning support provision

Community Nursing Services in England

This open access book provides an historical account of the ways in which community nursing services in England have been shaped by policy changes, from the inception of the NHS in 1948 to the present day. Focusing on policies regarding the organisation and provision of community nursing services, it offers an important assessment of how community nursing has evolved under successive governments. The book also provides reflections on how historic policies have influenced the service of today, and how lessons learnt from the past can inform organisation and delivery of current and future community nursing services. It is an important resource for those researching community nursing and health services, as well as practitioners and policy makers

Exploring the multiple policy objectives for Primary Care Networks: a qualitative interview study with national policy stakeholders

Objectives: English general practice is suffering a workforce crisis, with GPs retiring early and trainees reluctant to enter the profession. To address this, additional funding has been offered, but only through participation in collaborations known as Primary Care Networks (PCNs). This study explored national policy objectives underpinning PCNs, and mechanisms expected to help achieve these, from the perspective of those driving the policy. Design: Qualitative semi-structured interviews and policy document analysis. Setting and participants: National level policy maker and stakeholder interviewees (n=16). Policy document analysis of Network Contract Direct Enhanced Service draft service specifications. Analysis: Interviews were transcribed, coded, and organised thematically according to policy objectives and mechanisms. Thematic data was organised into a matrix so prominent elements to be identified and emphasised accordingly. Themes were considered alongside objectives embedded in PCN draft service delivery requirements. Results: Three themes of policy objectives and associated mechanisms were identified:(1) Supporting general practice;(2) Place-based inter-organisational collaboration;(3) Primary care ‘voice’. Interviewees emphasised and sequenced themes differently suggesting meeting objectives for one was necessary to realise another. Interviewees most closely linked to primary care emphasised the importance of(1). The objectives embedded in draft service delivery requirements primarily emphasised(2). Conclusions: These policy objectives are not mutually exclusive but may imply different approaches to prioritising investment or necessitate more explicit temporal sequencing, with the stabilisation of a struggling primary care sector probably needing to occur before meaningful engagement with other community service providers can be achieved or a ‘collective voice’ is agreed. Multiple objectives create space for stakeholders to feel dissatisfied when implementation details do not match expectations, as the negative reaction to draft service delivery requirements illustrates. Our study offers policy makers suggestions about how confidence in the policy might be restored by crafting delivery requirements so all groups see opportunities to meet favoured objectives

Relationship between quality of care and choice of clinical computing system: Retrospective analysis of family practice performance under the UK's quality and outcomes framework

OBJECTIVES: To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system. DESIGN: Retrospective longitudinal study. SETTING: Data for 2007–2008 to 2010–2011, extracted from the clinical computer systems of general practices in England. PARTICIPANTS: All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice. MAIN OUTCOME MEASURES: Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement. RESULTS: Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels). CONCLUSIONS: Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system

Exploring changes in patient experience with increasing practice size: observational study using data from the General Practice Patient Survey

Background For the last few years, English general practices, which are traditionally small, have been encouraged to work together to serve larger populations of registered patients, by merging or collaborating with each other. Meanwhile, patient surveys suggest worsening continuity of care and access to care. Aim To explore whether increasing size of practice population and working collaboratively are linked to changes in continuity of care or access to care. Design and setting Observational study in English general practice using data on patient experience, practice size and collaborative working Methods The main outcome measures were General Practice Patient Survey practice-level proportions of patients reporting positive experiences of access and relationship continuity of care. We compared change in proportions 2013-2018 among practices that had grown and those that had stayed about the same size. We also compared patients’ experiences by whether practices were working in close collaborations or not in 2018. Results. Practices that had grown in population size had a greater percentage fall in continuity of care, by 6.6% (95% confidence interval 4.3% to 8.9%) than practices that had stayed about the same size, after controlling for other factors. There was no similar difference in relation to access to care. Practices collaborating closely with others had marginally worse continuity of care than those not working in collaboration and no important differences in access. Conclusion Concerns that larger general practice size threatens continuity of care may be justified

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

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