Since April 2013, we have been investigating the changing public health system in England. These changes came about as a result of the Health and Social Care Act (2012) and have had profound implications for the organisation and delivery of public health. Prior to the reforms, the public health system was criticised as lacking synergy and suffering from inefficiencies due to overlapping responsibilities. Hence a key objective of government policy was to address the perceived fragmentation through a number of changes made to the structures and organisation of public health functions, chiefly by moving public health into Local Authorities (LAs) in order to:
- increase the emphasis on public health and disease prevention;
- create a more joined-up system with clearer leadership;
- have a greater impact on the wider determinants of health at local level.
Examining the impact of such changes has been challenging, especially in the context of the broader changes to the health and social care system, to other government policies in areas such as education and welfare and the wider austerity environment.
Transferring public health activities into local government sought to build on the developing role of Local Authorities (LAs) in shaping local places to create healthier environments through spatial planning and local initiatives to improve health and wellbeing. At the same time a new body, Public Health England (PHE), was created to bring national health service leadership and commissioning and further changes were implemented with the creation of NHS England (NHSE) – at ‘arm’s length’ from Government – and Clinical Commissioning Groups (CCGs) which commission healthcare services at a local level . These structural changes have had wide ranging implications for the way in which the public health function is approached, organised and delivered. Since 2013 the key responsibility for improving the health of local populations, including reducing health inequalities, rests with democratically accountable upper tier and unitary LAs - although the NHS retains some responsibilities for protecting and improving the population’s health and reducing health inequalities through all its clinical activity.
Throughout our research we utilised ‘systems thinking’ to help us to focus on inter-relationships and emphasise holistic thinking gathered from multiple perspectives. This enabled us to describe what we found to be “a chaotic, sprawling, dynamic set of practices which were often intensely political, and a set of activities that might more closely resemble a non-system”, which was still developing as our research was conducted.
Our most recent report, is based on the findings from the last 3 years and included an initial scoping review; a review of the Communities and local Government Select Committee investigation (2013) into the proposed changes; interviews with national stakeholders; case studies in 5 LA areas (including interviews, observations, collection of documentation) and two rounds of web-based surveys (of Directors of public health and elected councillors with roles in public health) in 2014 and 2015.
Our research showed that initially LA public health teams concentrated on developing the structures and processes required for effective operation (Gadsby et al 2014). We demonstrate that this concern with structures and organisation has continued (Peckham et al 2016). Financial insecurity created additional problems with LAs sometimes unsure of the details of their financial settlement from government until many contracts had been negotiated. Budget cuts across other departments within LAs also brought pressures to public health teams, as costs were transferred and shared across departments. Similarly contracts have received new scrutiny, and both existing and new contracts have had to be (re)negotiated within a new provider landscape.
The organisational position of the public health team and the director of public health were also found to be important in terms of ability to influence strategic decision-making and work with other departments. System co-ordination remained an area where roles and responsibilities of various actors were not always clear. In addition, actors within the system had to negotiate ways of working with others, in a situation where much was new and still changing. This was further complicated in two–tier council areas where responsibilities are spread between organisations creating additional complexities of inter-organisational working. However, our surveys (Jenkins et al 2015, Jenkins et al 2016) showed public health teams in two-tier authorities appeared to have fewer capacity issues in terms of supporting the information needs of CCGs.
Our research provides an early overview of the development of the public health system in England (2013-15) and highlights some important issues that have both policy and practice implications including:
- support for a stronger LA role in public health;
- a system still in flux and some continuing confusion about organisational responsibilities in terms of commissioning;
- financial constraint impacting on capacity of public health teams alongside broader financial constraint in local government;
- competing policy objectives; an ongoing struggle between local agendas (e.g. tackling inequalities) and a central government push (e.g. towards integration);
- some innovation and creativity in using public health resources, but also some concern expressed about inappropriate use of public health funding;
- the development of collaborative work between some LA departments, but some poor linkages with CCGs;
- distinct differences in development across our sites.
Overall, our findings suggest that the development of the new public health system in England is still in progress with both the internal organisation of public health in LAs, the NHS and PHE in a continuing state of flux. Despite much activity around the re-organisation of systems, structures and processes, which have had important consequences for roles, relationships and functions, we haven’t seen a corresponding shift in priorities and strategies. We identified a mismatch between the rhetoric at policy level, emphasising the importance of prevention and the reality, which has seen cuts in public health funding. We found that the Health and Social Care Act (2012) and associated policies paid insufficient attention to the nature and quality of relationships across the various organisations and individuals that constitute the new public health system. As a result, some of the challenges identified during the passage of the Health and Social Care Bill have been averted, although many remain. Some of the opportunities identified have been realised, but many are highly dependent on a range of locally contextual factors.
Our findings also mirror those set out in another recent blog, where Brackley argues that more work is needed to recognise the value of public health professionals within local authorities, the long term benefits of the prevention agenda and that “interventions that cannot easily be measured – at least in the short-term – in pounds and pence” are important.
For more details and a wider discussion of our data and finding refer to our final report which has just been published.
James Brackley (2016) ‘Everything is public health’: opportunity or threat for local public health professionals? 24/5/16
Erica Gadsby, Stephen Peckham, Anna Coleman, Julia Segar, Neil Perkins, Linda Jenkins, and Donna Bramwell. (2014) PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined: First interim report: the scoping review. University of Kent, PRUComm.
L.M. Jenkins, D. Bramwell, A. Coleman, E.W. Gadsby, S. Peckham, N. Perkins, J. Segar (2015). Integration, influence and change in public health: findings from a survey of Directors of Public Health in England. Journal of Public Health Advance Access published October 20, 2015.
Stephen Peckham, Erica Gadsby, Anna Coleman, Linda Jenkins, Neil Perkins, Donna Bramwell, Jayne Ogilvie, Harry Rutter and Julia Segar (2016). PHOENIX: Public Health and Obesity in England – the New Infrastructure Examined: final Report. University of Kent, PRUComm.
Nick Riches, Anna Coleman, Erica Gadsby and Stephen Peckham (2014) The role of local authorities in health issues: a policy document analysis. Kent University, PRUComm.
The paper investigated how the formal national provisions for pricing in the National Health Service (which are a form of prospective payment, known as ‘Payment by Results’) are operationalized at local level. Transactions costs theory and existing evidence predict that actual practice often does not comply with contractual rules. A national study of pricing between 2011 and 2015 confirms this and indicates that such payment systems may not be appropriate to address the current financial and organizational challenges facing the NHS. As the NHS struggles radically to reconfigure services, it is necessary to reconsider the appropriateness of a wider range of pricing mechanisms to facilitate moving care out of hospitals.
The PHOENIX project examined 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. This report is the fifth and final report for the project. It should be considered alongside a first interim report (Gadsby et al 2014), focusing on our scoping study phase; a second interim report (Peckham et al 2015) focusing on our phase one case study research and first national survey; a first survey report (Jenkins et al 2015) and a report of the second survey (Jenkins et al 2016). The research commenced in April 2013 and involved three phases of interviews – a scoping study with key informants in 2013 and two phases of interviewing in five case study areas in 2014 and 2015. In total we conducted 108 interviews for the main phases of the research reported here and 23 initial scoping interviews reported in our first interim report (Gadsby et al 2014). In addition we undertook two national surveys in 2014 and 2015 of Directors of Public Health and lead councillors for health. This final report incorporates the findings of our phase two case study research and second national surveys of Directors of Public Health (DsPH) and councillors who lead on public health issues. It also draws on the findings of the previous two phases of the research.
Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.
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.
Following several versions of the NHS quasi market since 1990, a wide ranging set of reforms was introduced into the NHS under the recent Coalition government by the Health and Social Care Act 2012 (HSCA 2012). The idea behind these is the same as that behind previous versions of the NHS quasi market: that competition between a wider range of providers will produce the desired results of improved quality and greater efficiency. The HSCA 2012 made a direct correlation between competitive behaviour in the NHS and competition law. The Procurement, Choice and Competition Regulations No.2 2013 relate to sections 75-77 and 304 (9) and (10) of the HSCA 2012, and indicate that competitive procurement by commissioners is to be preferred, although not in all circumstances. Monitor (the former NHS Foundation Trust regulator) took on the role of economic regulator for the whole of the NHS. Along with the national competition authorities (being, since April 2014 the Competition and Markets Authority, and prior to that, The Office of Fair Trading and the Competition Commission), has powers to enforce competition law to prevent anti-competitive behaviour.
At the same time, it is still necessary for providers of care to cooperate with each other in order to deliver high quality care. There are many aspects of care quality where cooperation is needed, such as continuity of care as patients move between organisations, and sharing of knowledge between clinicians. Monitor is also responsible for promoting co-operation. It is the role of NHS commissioners (including Clinical Commissioning Groups ‘CCGs’), however, to ensure that the appropriate levels of competition and cooperation exist in their local health economies.
During the course of this study, an important policy document, The Five Year Forward View (5YFV) was published by NHS England in October 2014. This did not mention competition between organisations and instead focussed on how organisations in the NHS need to cooperate with each other, and in fact at times merge to form larger organisations. And it should be noted that there have been no relevant legislative changes, so the HSCA 2012 remains in force. While studies have noted that incentives for competition and cooperation exist in healthcare, few have researched the interaction between the two. There was a need to investigate the way in which local health systems were managed to ensure that cooperative behaviour was appropriately coexisting with competition.
This 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 (CH).
The Health and Social Care Act 2012 gave the responsibility for commissioning primary care services to NHS England (NHSE). Part of the rationale for this was to move towards a more standardised model of primary care commissioning. However, it has become clear since 2010 that local flexibility and understanding is also required in order to properly match primary care provision to the needs of an aging population. Primary care co-commissioning was first mooted in the Call to Action in 2014, where “joint commissioning” was identified as one of national level supports to improve general practice. In May 2014, it was officially announced that CCGs would get ‘new powers’ under a new commissioning initiative. There are 3 levels of responsibility; (1) ‘greater involvement’ (where CCGs would have ‘influence’ but not take the lead in shaping primary care locally), (2) joint commissioning (where CCGs would set up a joint committee with NHSE AT), and (3) delegated authority (where CCGs would take over budgets from NHSE Area Teams and take the lead in primary care commissioning). Initially there was no clear expectation that CCGs would move from Level 1 and 2 to taking on full responsibility (Level 3) over time. However, one year on, CCGs operating at Level 1 and 2 were encouraged to consider applying for full delegation. This report aims to explore the uptake of primary care co-commissioning nationally, develop an understanding of the rationale underlying the policy and the expected outcomes, and understand the scope of co-commissioning activity and the process of change.
Tuesday 19 April 2016, 10am to 4pm
Friends Meeting House, Euston, London
The aim of this PRUComm seminar is to provide a forum to discuss current commissioning issues and system of change in England including:
- Current policy developments
- Research fidnings from PRUComm research on commissioning, competition and public health
- Performance and governance issues
- Jonathan Walden (NHS Commissioning Policy and Sponsorship, Commissioning Policy Lead)
- Dr Imelda McDermott (PRUComm, University of Manchester)
- Dr Iestyn Williams (Health Services Management Centre, University of Birmingham)
- Dr Erica Gadsby (PRUComm, University of Kent)
- Dr Pauline Allen (PRUComm, London School of Hygine & Tropical Medicine)
- Panel discussion on the future of commissioning: Professor Kath Checkland (PRUComm, University of Manchester), Dr Julia Simon (NHS England), Dr David Paynton (Royal College of General Practice), and Julie Wood (Chief Executive, NHS Clinical Commissioners)
Within the English NHS, Clinical Commissioning Groups (CCGs) were designed to increase clinical involvement in commissioning – it was thought that GPs’ knowledge of patients’ needs and local health systems would drive more patient-focused commissioning built around local needs. This new report asks if greater involvement has worked and if so, what specifically has worked? It could be argued that there is a fair amount of variation across CCGs in terms of clinical engagement so this report asks some pertinent questions.
One of the main focusses of the Health and Social Care Act 2012 (implemented from 2013) was on the development of Clinical Commissioning Groups (CCGs) to replace Primary Care Trusts (PCTs) in commissioning healthcare for their local populations. This report presents the findings from a second phase of our ongoing study following the development of CCGs in England since 2011.
In the first phase of this study (January 2011 to September 2012), we followed the development of CCGs from birth to authorisation i.e. from their involvement in the ‘pathfinder’ programme and officially becoming sub-committees of their local PCT Cluster until their authorisation in April 2013. One of the issues highlighted by our participants in the first phase of the study was the perception of GP ‘added value’. The aim of the second phase of our study was therefore to follow up those claims made in the first phase around issues of GP ‘added value’. We explored further the potential added value that clinicians, specifically GPs, bring to the commissioning process in interviews, and followed this up with observations of commissioners at work.
Our research used ‘Realist Evaluation’ (Pawson & Tilley, 1997). This approach involves: seeking out participants ‘programme theories’ as to how a particular policy or programme will bring about the desired outcomes; exploring the extent to which these programme theories ‘work’ in the real world; and examining in detail the mechanisms and contexts which underpin them. The
approach is often said to be exploring ‘what works, for whom, in what circumstances’? We applied this approach to GPs roles in CCGs, using interviews to find out what CCG leaders believe are the key aspects of their contribution to commissioning. We then observed a wide range of meetings in order to explore the extent to which the claims they made were borne out in practice, and to try to elucidate the important conditions which supported their roles.
- 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: Next steps in commissioning through competition and cooperation (2016-2017)
- 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]