The practice of commissioning healthcare from a private provider: learning from an in-depth case study

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background By 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’). Objectives To: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers. Design Mixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically. Results In the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners. Conclusions Commissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other. Funding The National Institute for Health Research Health Services and Delivery Research programme

Advance telephone calls ahead of reminder questionnaires increase response rate in non-responders compared to questionnaire reminders only : The RECORD phone trial

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Highest weight Macdonald and Jack Polynomials

Fractional quantum Hall states of particles in the lowest Landau levels are described by multivariate polynomials. The incompressible liquid states when described on a sphere are fully invariant under the rotation group. Excited quasiparticle/quasihole states are member of multiplets under the rotation group and generically there is a nontrivial highest weight member of the multiplet from which all states can be constructed. Some of the trial states proposed in the literature belong to classical families of symmetric polynomials. In this paper we study Macdonald and Jack polynomials that are highest weight states. For Macdonald polynomials it is a (q,t)-deformation of the raising angular momentum operator that defines the highest weight condition. By specialization of the parameters we obtain a classification of the highest weight Jack polynomials. Our results are valid in the case of staircase and rectangular partition indexing the polynomials.Comment: 17 pages, published versio

Chaos and Noise in a Truncated Toda Potential

Results are reported from a numerical investigation of orbits in a truncated Toda potential which is perturbed by weak friction and noise. Two significant conclusions are shown to emerge: (1) Despite other nontrivial behaviour, configuration, velocity, and energy space moments associated with these perturbations exhibit a simple scaling in the amplitude of the friction and noise. (2) Even very weak friction and noise can induce an extrinsic diffusion through cantori on a time scale much shorter than that associated with intrinsic diffusion in the unperturbed system.Comment: 10 pages uuencoded PostScript (figures included), (A trivial mathematical error leading to an erroneous conclusion is corrected

Enabling recruitment success in bariatric surgical trials: pilot phase of the By-Band-Sleeve study

This is the final version. Available on open access from Springer Nature via the DOI in this recordData availability: The data (transcripts) that support the findings of this study are available on request from the corresponding author. The data are not publicly available because of them containing information that could compromise privacy/consent, but the authors will be able to consider specific requests on a case-by-case basis.BACKGROUND: Randomized controlled trials (RCTs) involving surgical procedures are challenging for recruitment and infrequent in the specialty of bariatrics. The pilot phase of the By-Band-Sleeve study (gastric bypass versus gastric band versus sleeve gastrectomy) provided the opportunity for an investigation of recruitment using a qualitative research integrated in trials (QuinteT) recruitment intervention (QRI). PATIENTS/METHODS: The QRI investigated recruitment in two centers in the pilot phase comparing bypass and banding, through the analysis of 12 in-depth staff interviews, 84 audio recordings of patient consultations, 19 non-participant observations of consultations and patient screening data. QRI findings were developed into a plan of action and fed back to centers to improve information provision and recruitment organization. RESULTS: Recruitment proved to be extremely difficult with only two patients recruited during the first 2 months. The pivotal issue in Center A was that an effective and established clinical service could not easily adapt to the needs of the RCT. There was little scope to present RCT details or ensure efficient eligibility assessment, and recruiters struggled to convey equipoise. Following presentation of QRI findings, recruitment in Center A increased from 9% in the first 2 months (2/22) to 40% (26/65) in the 4 months thereafter. Center B, commencing recruitment 3 months after Center A, learnt from the emerging issues in Center A and set up a special clinic for trial recruitment. The trial successfully completed pilot recruitment and progressed to the main phase across 11 centers. CONCLUSIONS: The QRI identified key issues that enabled the integration of the trial into the clinical setting. This contributed to successful recruitment in the By-Band-Sleeve trial-currently the largest in bariatric practice-and offers opportunities to optimize recruitment in other trials in bariatrics.National Institute for Health Research Health Technology Assessment ProgrammeMedical Research Council (MRC

The study of metaphor as part of Critical Discourse Analysis

This article discusses how the study of metaphoric and more generally, figurative language use contributes to critical discourse analysis (CDA). It shows how cognitive linguists’ recognition of metaphor as a fundamental means of concept- and argument-building can add to CDA's account of meaning constitution in the social context. It then discusses discrepancies between the early model of conceptual metaphor theory and empirical data and argues that discursive-pragmatic factors as well as sociolinguistic variation have to be taken into account in order to make cognitive analyses more empirically and socially relevant. In conclusion, we sketch a modified cognitive approach informed by Relevance Theory within CDA

Pathologies in International Policy Transfer:The Case of the OECD Tax Transparency Initiative

ABSTRACT The importance of international organizations to the development and diffusion of international policy norms is widely recognized but is increasingly tempered by an appreciation of the pathologies of policy transfer. Using a case study of the OECD’s campaign to promote transparency in global tax affairs, this paper identifies a new and relatively distinctive form of dysfunctional policy transfer. Specifically it argues that international organizations face bureaucratic incentives to promote weak or lowest common denominator standards in order to maximize their prospects of brokering successful international agreements. However the paper also notes that while international organizations may have a short-term interest in promoting weak standards, their longer-term legitimacy is often tied to the effectiveness of the standards they promote. It is argued that this dynamic often leads to incremental policy change