Accountability in the UK Healthcare System: An Overview

Recent changes in the English National Health Service (NHS) have introduced new complexities into the accountability arrangements for healthcare services. This commentary describes how the new organizational structures have challenged the traditional centralized accountability structures by creating a more dispersed system of governance for local healthcare commissioners. It sets the context of discussions about accountability in the UK NHS and then describes the key changes in England following the implementation of the NHS reforms in April 2013. The commentary concludes that while there is increased complexity of accountability within a more decentralized and fragmented healthcare system, the government's goal of achieving increased local autonomy and greater control by general practitioners (GPs) will probably not be realized. In particular, the system will continue to have strongly centralized aspects, with increased regulation and central political responsibility

An Exploration of the Wheel-Induced Feeding-Suppression

Anorexia nervosa is an enigmatic human condition typified by food-restriction that is often accompanied by extensive exercise. This has been modeled in rats in the wheel-induced feeding-suppression (WIFS) model. In this model, animals are given access to a running-wheel, which induces a volitional drop in food-consumption. Short periods of wheel access have induced a feeding-suppression which is effectively reversed by chlorpromazine administration (Adams et al., 2009). Recent attempts at replicating Adams et al.’s (2009) feeding-suppression have, however, been unsuccessful (Peckham et al., 2013). These attempts raised questions as to whether or not the existing methodology is most effective at suppressing food-consumption in rats. A reliable WIFS model using short terms of wheel-access is important if drugs are to be tested in this paradigm. The first part of this thesis focused on which factors are most important for a WIFS to be seen and to use these findings to develop a model that can easily incorporate drug administration. Experiment 1 tested if rats’ body weights or their amount of running could predict the size of the WIFS. Experiment 1 explored the changes in food-consumption of 64 rats by providing 4 days of 24 h wheel-access followed by 4 days of 3 h wheel-access several days later. Neither body weight nor wheel-turns were predictive of the WIFS following 24 h or 3 h wheel-access. Experiment 2 sought to explore the effects of prior wheel-exposure duration on future wheel experiences. This experiment was a partial replication of Experiment 1; but with half of the rats (n =17) receiving 3 h wheel-access before 24 h wheel-access. It was found that the feeding-suppression was not evident in wheel naïve rats on the first day they received 3 h of wheel-access but was evident with 3 h access in rats with prior 24 h wheel experience. It was also found that the eventual feeding-suppression was larger with 24 h than 3 h of wheel-access. Experiment 3 tested whether or not the time of day (morning or afternoon) that wheel-access is given was important to the WIFS which occurs over the subsequent 24 h and largely at night. This experiment provided 34 rats with 3 h wheel-access every third day for 4 wheel exposures. Time of wheel-access was found to affect running but not the feeding-suppression which was evident on each of the days following wheel-access. Experiments 1 to 3 led to the development of a paradigm used in Part 2. Part 2 of this thesis explored the endocannabinoid system’s (ECS) effects on the WIFS. Anorexia-like behaviours have been shown to directly affect the ECS. These changes in the ECS have been suggested as a sign of an underactive ECS in both humans (Gérard et al., 2011) and rats (Casteels et al., 2014). Interestingly, when cannabinoids are introduced to animals with wheel-access, food-consumption becomes elevated. This has been seen in a study using ∆9-tetrahydrocannabinol (THC), the main psychoactive ingredient in marijuana, where rats’ weight-loss was attenuated by the drug (Verty et al., 2011). It has also been suggested that URB597, a drug that increases levels of anandamide (an endogenous cannabinoid comparable to THC), similarly ‘restored’ food-consumption (Peckham et al., 2013). Two experiments were conducted to independently examine these drugs in a new WIFS model. Experiment 4a focused on URB597 (0, 0.17, 0.5, and 1.0 mg/kg) whereas Experiment 4b focused on ∆9-tetrahydrocannabinol (THC; 0, 0.125, and 0.25 mg/kg) – both administered immediately after locked or unlocked wheel-access. This new procedure was effective in reliably inducing a WIFS but neither drug was able to prevent the feeding-suppression: suggesting cannabinoids might not play an important role in the WIFS

The Role Of Local Authorities In Health Issues: A Policy Document Analysis

Prior to the passing of the Health and Social Care Act 2012 the Communities and Local Government (CLG) Select Committee conducted an investigation into the proposed changes to the Public Health System in England. The Committee considered 40 written submissions and heard oral evidence from 26 expert witnesses. Their report, which included complete transcripts of both oral and written submissions, provided a rich and informed data on which to base an analysis of the proposed new public health system. This report analyses the main themes that emerged from the evidence submissions and forms part of our preliminary work for PRUComm’s PHOENIX project examining the development of the new public health system

Primary care-led commissioning and public involvement in the English National Health Service. Lessons from the past.

Background: Patient and Public involvement (PPI) in health care occupies a central place in Western democracies. In England, this theme has been continuously prominent since the introduction of market reforms in the early 1990s. The health care reforms implemented by the current Coalition Government are making primary care practitioners the main commissioners of health care services in the National Health Service, and a duty is placed on them to involve the public in commissioning decisions and strategies. Since implementation of PPI initiatives in primary care commissioning is not new, we asked how likely it is that the new reforms will make a difference. We scanned the main literature related to primary care-led commissioning and found little evidence of effective PPI thus far. We suggest that unless the scope and intended objectives of PPI are clarified and appropriate resources are devoted to it, PPI will continue to remain empty rhetoric and box ticking. Aim: To examine the effect of previous PPI initiatives on health care commissioning and draw lessons for future development. Method: We scanned the literature reporting on previous PPI initiatives in primary careled commissioning since the introduction of the internal market in 1991. In particular, we looked for specific contexts, methods and outcomes of such initiatives. Findings: 1. PPI in commissioning has been constantly encouraged by policy makers in England. 2. Research shows limited evidence of effective methods and outcomes so far. 3. Constant reconfi- guration of health care structures has had a negative impact on PPI. 4. The new structures look hardly better poised to bring about effective public and patient involvement

Is It Time to Explore the Health Policy Process Within Governance and Health Systems Frameworks?

There is clearly a need to improve the use of more robust policy theory on health policy analysis. Powell and Mannion in an editorial on the relationship between health policy analysis and the wider field of public policy theory note, as others have done before, the limited application of policy theory in health policy analysis. However, they also highlight that within the health policy analysis arena new models have emerged which have wider use within policy analysis such as the health policy triangle. While Powell and Mannion suggest that health policy analysis can take one of two paths I argue that we should be developing more integrated frameworks of health policy processes, governance and systems which would involve the use of robust public policy theories and models

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

PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined First interim report: the scoping review

The PHOENIX project aims to examine the impact of structural changes to the health and care system in England on the functioning of the public health system, and on the approaches taken to improving the public’s health. The scoping review has now been completed. During this phase we analysed: Department of Health policy documents (2010-2013), as well as responses to those documents from a range of stakeholders; data from 22 semi-structured interviews with key informants; and the oral and written evidence presented at the House of Commons Communities and Local Government Committee on the role of local authorities in health issues. We also gathered data from local authority (LA) and Health and Wellbeing Board (HWB) websites and other sources to start to develop a picture of how the new structures are developing, and to collate demographic and other data on local authorities. A number of important themes were identified and explored during this phase. In summary, some key points related to three themes - governance, relationships and new ways of working - were: The reforms have had a profound effect on leadership within the public health system. Whilst LAs are now the local leaders for public health, in a more fragmented system, leadership for public health appears to be more dispersed amongst a range of organisations and a range of people within the LA. At national level, the leadership role is complex and not yet developed (from a local perspective). Accountability mechanisms have changed dramatically within public health, and many people still seem to be unclear about them. Some performance management mechanisms have disappeared, and much accountability now appears to rely on transparency and the democratic accountability that this would (theoretically) enable. The extent to which ‘system leaders’ within PHE are able to influence local decisions and performance will depend on the strength of relationships principally between the LA and the local Public Health England centre. These relationships will take time to develop. Many people have faced new ways of working, in new settings, and with new relationships to build. Public health teams in LAs have faced the most profound of these changes, having gone from a position of ‘expert voice’ to a position where they must defend their opinions and activities in the context of competing demands and severely restricted resources. Public health staff may require new skills, and may need to seek new ‘allies’ to thrive in the new environment. HWBs could be crucial in bringing together a fragmented system and dispersed leadership. The next phase of data collection will begin in March with the initiation of case study work. National surveys will be conducted in June/July this year (2014), and at the same time the following year. In this work, we will further explore the following themes: relationships, governance, decision making, new ways of working, and opportunities and difficulties

Decentralisation – A Portmanteau Concept That Promises Much but Fails to Deliver? Comment on “Decentralisation of Health Services in Fiji: A Decision Space Analysis”

Decentralisation has been described as an empty concept that lacks clarity. Yet there is an enduring interest in the process of decentralisation within health systems and public services more generally. Many claims about the benefits of decentralisation are not supported by evidence. It may be useful as an organising framework for analysis of health systems but in this context it lacks conceptual clarity and particularly often ignores level context issues given the focus on a principal-agent/vertical centre/local axis or other aspects of limits on autonomy such as standards for professional practice. Both these aspects are relevant in discussing the establishment of “decentralised” health centres in Fiji. In the end decentralisation may be nothing more than a useful descriptive label that can be used in an increasingly wide range of ways but actually have little meaning in practice as an analytical concept