Clinical leadership through commissioning: Does it work in practice?

In tune with much international practice, the English National Health Service has been striving to transform health care provision to make it more affordable in the face of rising demand. At the heart of a set of recent radical reforms has been the launch of ‘clinical commissioning’ using the vehicle of local groups of General Practitioners (GPs). This devolves a large portion of the total healthcare budget to these groups. National government policy statements make clear that the expectation is that the groups will ‘transform’ the organization and provision of health services. In this article we draw upon interviews, observations and analysis of internal documents to make an assessment of the extent to which clinical leaders have seized the opportunity presented by the creation of these groups to attempt transformative service redesign

Ruling the regions: an interpretivist analysis of institutional development in the English regional assemblies

This thesis presents an interpretivist analysis of institutional development in the English regional assemblies. It presents a history of institutional development in the regions, arriving at a conceptualization of this tier as a site of ‘institutional ambiguity.’ Exploring the theoretical bases of institutions and conducting a thorough critique of the schools of institutionalism, this thesis takes forward the theory of ‘constructivist institutionalism.’ A theoretical framework focussed on the processes of institutional design and change is built from constructivist institutionalism, as is a complementary and coherent methodological package to explore the empirical sites of the West Midlands and North West regional assemblies. The concepts of ‘frames’ and ‘stories’ are set out as interpretivist tools through which the primary interview data is analysed, to capture the development of the democratic institution of representation as it relates to the local government and stakeholder actors involved in these two regional assemblies. This thesis finds actors engaged in interplay between structure and agency while contributing to the processes of institutional design and change. Actors draw together their ideas with the pre-existing institutional context, relating them together in discursive constructions (frames, stories) that underpin their strategic-relational action, which in turn underpins the institutions of the assemblies. Regional representation transpires to mimic local governmental norms due to the dominant influence of the pre-existing context

Mobilizing Clinical Leadership in and around Clinical Commissioning Groups: A mixed methods study

Background: A core component of the Health and Social Care Act 2012 was the idea of devolving to GPs a health service leadership role for service redesign. For this purpose, new clinical commissioning groups (CCGs) were formed in the English NHS.Objectives: This research examined the extent and the methods by which clinicians stepped forward to take-up a leadership role in service redesign using CCGs as a platform.Design: The project proceeded in five phases: a scoping study across 15 CCGs; the design and administration of a national survey of all members of CCG governing bodies in 2014; six main in-depth case studies; a second national survey of governing body members in 2016 which allowed longitudinal comparisons; and a fifth phase of international comparisons.Participants: In addition to GPs serving in clinical lead roles for CCGs, the research also included insights from Accountable Officers and other managers, perspectives from secondary care and other provider organisations; local authority councillors and staff, patients and public, and other relevant bodies.Results: Instances of the exercise of clinical leadership utilizing the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. But, we found other cases where clinicians had stepped forward to bring about meaningful improvements to services. The most notable cases involved the design of integrated care for frail elderly patients and others with long term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: strategy-level work at CCG board level; mid-range operational planning and negotiation at programme board level; and thirdly, the arena of practical implementation leadership at the point of delivery. The arena of the CCG board provided the legitimacy for strategic change; the programme boards worked-through the competing logics of markets, hierarchy and networks; the practice arena allowed the exercise of clinical leadership in practical problem-solving, detailed learning and routinisation of new ways of working at a common-sense everyday level.Conclusions: Despite the variation in practice, we found significant examples of clinical leaders forging new modes of service design and delivery. A great deal of the service redesign effort was directed at compensating for the fragmented nature of the NHS – part of which had been created by the 2012 reforms. This is the first study to reveal details of such work in a systematic way

GP leadership in clinical commissioning groups: a qualitative multi-case study approach across England

Background Clinical commissioning groups (CCGs) were established in England in 2013 to encourage GPs to exert greater influence over the processes of service improvement and redesign in the NHS. Little is known about the extent and the ways in which GPs have assumed these leadership roles. Aim To explore the nature of clinical leadership of GPs in CCGs, and to examine the enablers and barriers to implementing a policy of clinical leadership in the NHS. Design and setting A qualitative multi-case study approach in six localities across England. The case studies were purposefully sampled to represent different geographical localities and population demographics, and for their commitment to redesigning specified clinical or service areas. Method Data were collected from the case study CCGs and their partner organisations using a review of relevant documents, semi-structured individual or group interviews, and observations of key meetings. The data were analysed thematically and informed by relevant theories. Results GPs prefer a collaborative style of leadership that may be unlikely to produce rapid or radical change. Leadership activities are required at all levels in the system from strategy to frontline delivery, and the leadership behaviours of GPs who are not titular leaders are as important as formal leadership roles. A new alliance is emerging between clinicians and managers that draws on their different skillsets and creates new common interests. The uncertain policy environment in the English NHS is impacting on the willingness and the focus of GP leaders. Conclusion GPs are making an important contribution as leaders of health service improvement and redesign but there are significant professional and political barriers to them optimising a leadership role

Towards a framework for enhancing procurement and supply chain management practice in the NHS: lessons for managers and clinicians from a synthesis of the theoretical and empirical literature

Background: This review provides intelligence to NHS managers and clinicians involved in commissioning and procurement of non-pay goods and services. It does this in the light of ongoing pressure for the NHS to save money through a combination of cost cutting, productivity improvements and innovation in service delivery, and in the context of new commissioning structures developing as a result of the Health and Social Care Act 2012 (Great Britain. Health and Social Care Act 2012. Chapter 7. London: The Stationery Office; 2012). Objectives: We explore the main strands of the literature about procurement and supply chain management (P&SCM); consider the extent to which existing evidence on the experiences of NHS managers and clinicians involved in commissioning and procurement matches these theories; assess how the empirical evidence about different P&SCM practices and techniques in different countries and sectors might contribute to better commissioning and procurement; and map and evaluate different approaches to improving P&SCM practice. Review method: We use a realist review method, which emphasises the contingent nature of evidence and addresses questions about what works in which settings, for whom, in what circumstances and why. Adopting realist review principles, the research questions and emerging findings were sense-checked and refined with an advisory group of 16 people. An initial key term search was conducted in October 2013 across relevant electronic bibliographic databases. To ensure quality, the bulk of the search focused on peer-reviewed journals, though this criterion was relaxed where appropriate to capture NHS-related evidence. After a number of stages of sifting, quality checking and updating, 879 texts were identified for full review. Results: Four literatures were identified: organisational buying behaviour; economics of contracting; networks and interorganisational relationships; and integrated supply chain management (SCM). Theories were clustered by their primary explanatory focus on a particular phase in the P&SCM process. Evidence on NHS commissioning and procurement practice was found in terms of each of these phases, although there were also knowledge gaps relating to decision-making roles, processes and criteria at work in commissioning organisations; the impact of power on collaborative interorganisational relationships over time; and the scope to apply integrated SCM thinking and techniques to supply chains delivering physical goods to the NHS. Evidence on P&SCM practices and techniques beyond the NHS was found to be highly fragmented and at times contradictory but, overall, demonstrated that matching management practice appropriately with context is crucial. Conclusions: We found that the P&SCM process involves multiple contexts, phases and actors. There are also a wide variety of practices that can be used in each phase of the P&SCM process. Thinking about how practice might be improved in the NHS requires an approach that enables the simplification of the complex interplay of factors in the P&SCM process. Portfolio-based approaches, which provide a contingent approach to considering these factors, are recommended. Future work should focus on conflicting preferences in NHS commissioning and procurement and the role of power and politics in conflict resolution; the impact of power on the scope for collaboration in health-care networks; and the scope to apply integrated SCM practices in NHS procurement organisations. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Implementation of pay for performance in primary care:a qualitative study 8 years after introduction

BACKGROUND: Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF). AIM: To obtain a longer term perspective on the implementation of the QOF. DESIGN AND SETTING: Qualitative study with 47 health professionals in 23 practices across England. METHOD: Semi-structured interviews. RESULTS: Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients’ best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences. CONCLUSION: Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care