In 2016, we reported our research on NHS commissioners’ and providers’ understandings and use the rules on competition, and our investigation of how commissioners used competitive and cooperative commissioning mechanisms at local level from 2013 to 2015. Since 2015, when the last phase of field work was undertaken, the legal framework governing the procurement of clinical services has not changed. The generally pro-competitive provisions of the Health and Social Care Act 2012 (HSCA 2012) remain in force. In addition, the Public Contracts Regulations 2015 (PCR 2015) came into force in April 2016 introducing further requirements in respect of competitive procurement. Despite no substantive changes in the legislation governing procurement processes, since 2015 there has been a considerable national policy shift towards cooperative methods of commissioning.
Firstly, the ‘Five Year Forward View’ (5YFV) published by the NHS England (NHSE) in October 2014 instigated a number of the New Models of Care (NMC) vanguard sites. Many of these involved the merger or at least closer cooperation of a range of NHS organisations. This view was reinforced by the national planning guidance issued in late 2015 (Delivering the Forward View: NHS Planning Guidance 2016/17-2020/21). This document stated that the NHS should concentrate on local, placed based planning to be achieved by cooperation between local stakeholders. The plans were to be called ‘Sustainability and Transformation Plans’, and the groups of organisations were named ‘Sustainability and Transformation Partnerships' (STPs). These cooperative modes of coordination were regarded as the preferable (and in fact, mandated) method by which health services would be planned and commissioned. Lastly, the notion of Accountable Care Organisations (ACOs) or Systems (ACSs) was introduced in 2017. These were seen as natural successors to STPs under which NHS organisations would either merge formally or work in close cooperation. In the light of these policy developments there was a need to investigate the way in which local commissioners and providers managed the interplay between cooperation and competition in commissioning clinical services.
The aims of this stage of the field work remained the same as those of the initial study. The project aimed to investigate how commissioners in local health systems managed the interplay of competition and cooperation in their local health economies, looking at acute and community health services (CHS).
The English Health and Social Care Act 2012 gave GP-led clinical commissioning groups (CCGs) responsibility for commissioning the majority of healthcare services for their registered population. However, responsibility for commissioning primary care services was given to a new national body, NHS England (NHSE), to avoid conflicts of interest and because of a perceived need for a standardised and consistent approach to commissioning. It soon became apparent that NHSE was struggling to move beyond a transactional approach to commissioning, focused on payments and contract management. When Simon Stevens took over as the Chief Executive of NHSE (April 2014), he advocated transferring responsibility for commissioning primary care services from NHSE to CCGs. Two years on, how have CCGs responded to their new responsibilities and what challenges do they face?
Read our debate and analysis paper published in the British Journal of General Practice >>
Objectives From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.
Design We carried out two telephone surveys using a sample of CCGs. We also used a qualitative case study approach and collected data using interviews and meeting observations in four sites (CCGs).
Setting/participants We conducted 57 telephone interviews and 42 face-to-face interviews with general practitioners (GPs) and CCG staff involved in primary care co-commissioning and observed 74 meetings of CCG committees responsible for primary care co-commissioning.
Results Conflicts of interest were seen as an inevitable consequence of CCGs commissioning primary care. Particular problems arose with obtaining unbiased clinical input for new incentive schemes and providing support to GP provider federations. Participants in meetings concerning primary care co-commissioning declared conflicts of interest at the outset of meetings. Different approaches were pursued regarding GPs involvement in subsequent discussions and decisions with inconsistency in the exclusion of GPs from meetings. CCG senior management felt confident that the new governance structures and policies dealt adequately with conflicts of interest, but we found these arrangements face limitations. While the revised NHSE statutory guidance on managing conflicts of interest (2016) was seen as an improvement on the original (2014), there still remained some confusion over various terms and concepts contained therein.
Conclusions Devolving responsibility for primary care co-commissioning to CCGs created a structural conflict of interest. The NHSE statutory guidance should be refined and clarified so that CCGs can properly manage conflicts of interest. Non-clinician members of committees involved in commissioning primary care require training in order to make decisions requiring clinical input in the absence of GPs.
To find out if NHS culture is changing, our research investigated the views of managers about competition in the NHS after the enactment of the HSCA 2012 to examine the extent to which marketisation has become an internalised feature of NHS commissioning practices, and explore how far this is actually changing the NHS in any fundamental way. We found that managers remain committed to collaboration, but pockets of competitive thinking are present.
The Health and Social Care Act 2012 (‘HSCA 2012’) introduced a new, statutory, form of regulation of competition into the National Health Service (NHS), while at the same time recognising that cooperation was necessary. NHS England’s policy document, The Five Year Forward View (‘5YFV’) of 2014 placed less emphasis on competition without altering the legislation. We explored how commissioners and providers understand the complex regulatory framework, and how they behave in relation to competition and cooperation.
Design We carried out detailed case studies in four clinical commissioning groups, using interviews and documentary analysis to explore the commissioners’ and providers’ understanding and experience of competition and cooperation.
Setting/participants We conducted 42 interviews with senior managers in commissioning organisations and senior managers in NHS and independent provider organisations (acute and community services).
Results Neither commissioners nor providers fully understand the regulatory regime in respect of competition in the NHS, and have not found that the regulatory authorities have provided adequate guidance. Despite the HSCA 2012 promoting competition, commissioners chose mainly to use collaborative strategies to effect major service reconfigurations, which is endorsed as a suitable approach by providers. Nevertheless, commissioners are using competitive tendering in respect of more peripheral services in order to improve quality of care and value for money.
Conclusions Commissioners regard the use of competition and cooperation as appropriate in the NHS currently, although collaborative strategies appear more helpful in respect of large-scale changes. However, the current regulatory framework contained in the HSCA 2012, particularly since the publication of the 5YFV, is not clear. Better guidance should be issued by the regulatory authorities.
This is our fifth annual review of research and provides a brief overview of our research activities. Following confirmation last year of our extension until the end of 2018 we have now agreed a programme of work with the Department. This sees a stronger shift towards exploring the impact of system changes on commissioning. The introduction of Sustainability and Transformation Plans and new metapractice organisations creates a rapidly shifting landscape for the commissioning and delivery of healthcare in England.
We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.
Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.
Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.
The Quality and Outcomes Framework (QOF), an incentive scheme in general practice, was introduced across the UK in 2004 to link payment to delivery of primary medical care. Drivers for its introduction included the recognition that there were variations between general practices in the quality of care and the need to increase investment to improve morale and recruitment in primary care. QOF, in the early years, led to a reduction in inequalities in delivery of those aspects of care that it incentivised. Currently, there is little variation in QOF achievement between practices - most derive maximum, or near maximum income from it.
The QOF had other effects, encouraging nurse-led multidisciplinary management of chronic disease to deliver incentivised services, and better practice computerisation, so that delivery could be recorded. However, the extent to which high QOF achievement means a higher quality service in general practice is not clear. Quality in primary care is difficult to define, but it certainly encompasses more than is measured by QOF. It is now explicit NHS policy to improve other aspects of primary care – in particular, to deliver better integrated, holistic and patient-centred care and more effective primary prevention in primary care. Whether QOF can deliver these policies has been questioned, as have its role in reducing inequalities and its ability to deliver better population health.
NHS England commissioned the Centre for Health Services Studies at the University of Kent, on behalf of the Policy Research Unit in Commissioning and the Healthcare System (PRUComm), to review the evidence of effectiveness of QOF in the context of a changing policy landscape. We examined the most recent evidence that QOF influences behaviour in general practice and health outcomes, taking a broad view of primary care quality. We also considered the evidence that QOF helps sustain changes in primary care and effects of withdrawing QOF indicators using recent patterns of QOF achievement and the published literature.
The state of general practice remains a key talking point in UK healthcare with continuing concerns about difficulty of recruitment, practices closing and a general feeling that general practice is in crisis. The central policy response to this situation is the General Practice Forward View published in April 2016 which was developed from the 2015 10 Point Plan produced jointly by NHS England, the Department of Health, Health Education England, BMA and the RCGP. As part of the development work for the Forward View NHS England and the Department of Health commissioned the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) to undertake an evidence synthesis on GP recruitment, retention and re-employment - although given the paucity of literature on re-employment the review focused on recruitment and retention. The review was undertaken by Professor Stephen Peckham, Director of PRUComm, and Dr Catherine Marchand of the Centre for Health Services Studies at the University of Kent.
Overall, the published evidence in relation to GP recruitment and retention is limited and focused mainly on attracting GPs to underserved rural areas. However, the literature does provide some useful insights to factors that may support the development of specific strategies for the recruitment and retention of GPs. It was also evident that there are clear overlaps between strategies for supporting increased recruitment and retention.
Key factors that are relevant to the recruitment of GPs are primarily related to providing students with appropriate opportunities for contact with and positive exposure to general practice and general practitioners. Having good role models is particularly important and early exposure in pre-clinical training may be important in influencing future medical training choices. The training environment and location of training can also play important roles in improving recruitment to areas where there are shortages of trainees. Financial factors seem less important in influencing student’s choice for general practice – particularly in the current UK context.
More attention could be paid to the fit between skills and attributes with intellectual content and demands of the specialisation – in particular portraying general practice as a stimulating and interesting specialisation. It is also clear that factors such as lifestyle (flexibility, work-life balance, quality of life), social orientation and desire for a varied scope of practice are important factors contributing to decisions about choice of specialisation. Strategies that emphasise what are seen as the most important and rewarding aspects of the GPs job - facilities, autonomy of work, diversity of cases, education and employment opportunities for physician’s spouses in the practice location – all have a positive influence on recruitment.
Interestingly many of the factors relating to retention are similar to those related to recruitment. Positive factors as viewed by students and GPs about general practice as a profession – such as patient contact, variety, continuity of care – are intrinsic to what it means for them to be a GP. Recruitment factors highlighted positive role models, engagement with practices and socialisation into general practice while retention factors are similar in terms of supporting the ability of GPs to practice being a GP.
The evidence does suggest that tackling key aspects of job stress are important but supporting the key factors of how GPs view the essential nature of general practice in terms of patient contact may be more critical together with developing new opportunities for diversity of practice through sub-specialities and broader portfolio careers. As for the new ways of working, it is likely that the inclusion of nurses, pharmacists, and even social workers might help reduce the strain of the workload and burnout symptoms of GPs. GPs leave both for reasons of job dissatisfaction – possibly reflecting a frustration or a disappointment toward the changing roles in their practice - and also to retire before 60 years old, even if not discontent. Reasons may include lack of resilience to deal with stress but also a simple view that they have undertaken sufficient lifetime service. Generally the findings of this review are consistent with the wider literature on organisational behaviour and human resource management.
Based on our analysis of the evidence, the elements that are most likely to increase and influence recruitment in general practice include:
• exposure of medical students to successful GP role models
• early exposure to general practice
• supporting intrinsic motivational factors and career determinants
Despite continuing interest in using “golden handshakes” there is little evidence that financial targeted support will increase recruitment as recent experience in some areas of England have already demonstrated.
While we found no clear evidence of the effect of investment in retainer schemes and incentives to remain in practice on retention things that will possibly influence GPs to remain in practice include:
• supporting intrinsic factors of the job
• strategies to improve job satisfaction
• reducing job stressors such as work overload, lack of support and high demand
NHSE - IPSOS/MORI report>>
This report is part of the research of the Policy Research Unit in Commissioning and the Health Care System (PRUComm) on new models of contracting in the NHS, commissioned by the Department of Health.
Over the past few years the need to find new ways to integrate services has become an important policy priority in the English NHS. The formation of new organisational configurations in local health economies announced in the Five Year Forward View entails separate organisations working closely together to improve the integration of local services and allow the better use of resources. One way to achieve collaboration across organisational boundaries is through the adoption of new models of contracting, such as alliance contracting, prime provider contracting and outcome based contracting. Despite their relative novelty in the English NHS, these models have a history of use in other sectors such as construction and defence, as well as in the commissioning of public services in the UK and overseas.
This report summarises the findings of a literature review of the available evidence concerning the characteristics of these new contractual models and their implementation in other sectors. The available evidence is considered in order to draw out the lessons which may be learnt to aid the implementation of these models in the English NHS.
- Apr 2020: Commissioning Healthcare in England - Book Launch
- Nov 2019: Integrated Care Systems: What can current reforms learn from past research on regional co-ordination of health and care in England? A literature review
- Jan 2019: National evaluation of the Vanguard new care models programme. Interim report: understanding the national support programme
- Nov 2018: Understanding the new commissioning system in England: contexts, mechanisms and outcomes
- Nov 2018: Investigating recent developments in the commissioning system
- Jul 2018: Impact of removing indicators from the Quality and Outcomes Framework
- May 2018: Numbers of GPs who want out within 5 years at all-time high
- Mar 2018: Understanding primary care co-commissioning: Uptake, development, and impacts. Final report
- Mar 2018: Planning and managing primary care services - Lessons from the NHS in England
- Mar 2018: PRUComm Annual Research Seminar [Event]
- Mar 2018: PRUComm Annual Research Seminar [Event]
- Apr 2016: The future of commissioning [Event]
- Mar 2016: Examining the impact of the Health & Social Care Act: Examining developments in the English health system from 2013-2015 [Event]
- Feb 2013: Healthcare Commissioning Seminar: A summary
- Feb 2013 PRUComm research seminar on healthcare commissioning [Event]
- Jun 2011: How can evaluation contribute to health policy in England? [Event]