Annals of Public and Cooperative Economics, Feb 7, 2011
They are designed to increase the marketlike behaviour of providers of care with a view to improv... more They are designed to increase the marketlike behaviour of providers of care with a view to improving efficiency, quality and responsiveness of services. This paper is concerned with one aspect of those reforms: namely the policy to increase the diversity of types of providers of care to NHS patients. In this context, increasing diversity means that providers will not all be standard publicly owned NHS organizations. They can be publicly owned but autonomous, or independent (both in for-profit and not for profit). The paper discusses the wide range of organizational forms available, analyzing their governance structures It then discusses the small amount of evidence currently available about the performance of diverse providers of health care.
Taking the first era from the inception of the NHS through to 1974, this chapter documents the es... more Taking the first era from the inception of the NHS through to 1974, this chapter documents the establishment of the service as a home nursing service. Known as the 'tripartite era' because of the way provision of health services were divided between three types of bodies-Local Authorities (LA), Executive Councils of the Ministry of Health and Hospital Boards-this era would see a split enshrined between LA-provided community nursing services and medical services provided by the others. This split has been a feature of the NHS ever since, despite successive unifying re-organisations of the health service, and has come to define the way community nursing is perceived by policy apparent in this review. In line with the format of the chapters, we start to look at the role and function of district nurses (DNs) and begin to see how the role was focused on home care for the sick, management of infectious diseases and supporting doctors. We also begin to examine how DNs were managed and paid for and identify the enduring tensions in how they are organised-either geographically or attached to GP practices. We conclude this chapter with a brief paragraph summing up that for this era the role of district nurse services, despite becoming a national requirement, is rarely fully set out in policy. In other words, the district nursing service was largely invisible in policy terms.
This book brings together selected research on commissioning healthcare in the English NHS carrie... more This book brings together selected research on commissioning healthcare in the English NHS carried out by national policy research unit in commissioning and the healthcare system (PRUComm) between 2011 and 2018. PRUComm is funded by the English Department of Health’s Policy Research Programme. The bookexplores the changes to commissioning in the English NHS quasi market introduced by the Health and Social Care Act 2012 (HSCA 2012). It focuses on threemain areas: first, the development and operation of the newly formed commissioning bodies named Clinical Commissioning Groups (CCGs) which were supposed to increase clinical engagement; secondly, technical aspects of commissioning being the use of competition and cooperation by CCGs to commission care in the HSCA 2012 regulatory context encouraging competition,and the allocation of financial risk through contracts between commissioners and providers of care (including new forms of contract such as alliances); and thirdly the reorganisat...
COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective e... more COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective equipment (PPE) has complex origins. This article explores the long-lasting struggle for centralisation in NHS procurement and its impact on the current PPE crisis.
Policy driven change is challenging, with a significant gap between theory and practice. A key te... more Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid lea...
Accountability is at the heart of the concept of clinical governance. Not only must health profes... more Accountability is at the heart of the concept of clinical governance. Not only must health professionals strive to improve the quality of care, they must also be able to show that they are doing so. The notion of accountability is not new-clinicians have long been accountable to their professional regulatory bodies. However, recent scandals about dangerous practice by doctors have damaged confidence in the current system of peer-led self regulation and raised concerns about the limited accountability of doctors in particular. 1 2 The new requirement for primary care clinicians to be answerable to colleagues in their practice and their primary care group or trust can be seen as one of a range of responses to these concerns and is central to the notion of clinical governance. This paper will discuss how the notion of accountability in clinical governance can be understood and operationalised within primary care. It will use the clinical governance work of a London primary care group as a case study to illustrate mechanisms of accountability and will show how there are different forms of accountability between health professionals and others, relating to various aspects of performance. The paper will also consider the barriers to improved accountability and highlight tensions that are likely to arise.
Since the beginning of the 1990s the public health care system in England has been subject to ref... more Since the beginning of the 1990s the public health care system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilising a theory of new institutionalism this paper 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 marketisation 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.
International Journal of Public and Private Healthcare Management and Economics, 2012
Preferences have been analyzed extensively in health care, but few studies have examined how cult... more Preferences have been analyzed extensively in health care, but few studies have examined how culture driven preference formation may impact on resource allocation decisions in public and private health service delivery. This paper explores and develops a theoretical framework that distinguishes different approaches to institutionally and culturally informed preferences. The analysis shows that the appropriate approach depends on normative considerations and the particular health policy context which it is applied. In particular health policy cultures, mediating culture driven preferences (such as fatalism, hierarchism, individualism, egalitarianism and autonomy) which have not been used as part of health policy analysis before, challenge the roles of public and private health service providers. In view of the scarcity of studies in this field, the authors suggest a rationale for studies that enhance the understanding of how health policy cultures are embedded in normative health pol...
In England, policy piloting has become firmly established in almost all areas of public policy an... more In England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the ex...
Continuities and changes in policy concerning the organisational structure of the British Nationa... more Continuities and changes in policy concerning the organisational structure of the British National Health Service are evident throughout the last decade. This paper presents lessons learned from the internal market experience and discusses the extent to which New Labour policies have taken these into account. The role of decentralised contracts and central government direction in each system is explored. The internal market was less decentralised than expected, and direction from central government continued to be a key element. In the post internal market system, less faith has been placed in the capacity of contracts to improve quality of care, and centralised direction to set and enforce standards has increased. But simultaneously the mechanism of contracting has been retained and it is likely to be extended in increased dealings with the private sector. Efforts are also being made to curtail the high degree of centralisation in the early post internal market years.
We investigate how the formal national provisions for pricing in the NHS (which are a form of pro... more We investigate how the formal national provisions for pricing in the NHS (which are a form of prospective payment, known as Payment by Results) are operationalised at local level. Transactions costs theory and existing evidence predict that actual practice often does not comply with contractual rules. Our 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 organisational challenges facing the NHS.
Background. GPs have to respond to conflicting policy developments. As gatekeeper they are suppos... more Background. GPs have to respond to conflicting policy developments. As gatekeeper they are supposed to manage the growing demand for specialist services and as patient advocate they should be responsive to patients' preferences. We used an innovative approach to develop a referral guideline for patients with chronic knee pain that explicitly incorporates patients' preferences. Methods. A guideline development group of 12 members including patients, GPs, orthopaedic surgeons and other health care professionals used formal consensus development informed by systematic evidence reviews. They rated the appropriateness of referral for 108 case scenarios describing patients according to symptom severity, age, body mass, co-morbidity and referral preference. Appropriateness was expressed on scale from 1 ('strongly disagree') to 9 ('strongly agree'). Results. Ratings of referral appropriateness were strongly influenced by symptom severity and patients' referral preferences. The influence of other patient characteristics was small. There was consensus that patients with severe knee symptoms who want to be referred should be referred and that patient with moderate or mild symptoms and strong preference against referral should not be referred. Referral preference had a greater impact on the ratings of referral appropriateness when symptoms were moderate or severe than when symptoms were mild. Conclusions. Referral decisions for patients with osteoarthritis of the knee should only be guided by symptom severity and patients' referral preferences. The guideline development group seemed to have given priority to avoiding inefficient resource use in patients with mild symptoms and to respecting patient autonomy in patients with severe symptoms.
Chapter 2 provides the context, setting out the organisation and governance of commissioning in t... more Chapter 2 provides the context, setting out the organisation and governance of commissioning in the NHS. It includes a short summary of the architecture of commissioning pre-Health and Social Care Act (HSCA12), and highlights the important changes which were brought about by the Act, including the abolition of Primary Care Trusts and Strategic Health Authorities, the establishment of Clinical Commissioning Groups (CCGs), the creation of NHS England, transfer of commissioning responsibilities to different bodies (e.g. public health) and the setting up of local Health and Wellbeing Boards. The chapter also highlights the programme theories underlying the HSCA12, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Li... more This is an Open Access article distributed under the terms of the Creative Commons Attribution License
The Developing Architecture of System Management: Integrated Care Systems and Sustainability and ... more The Developing Architecture of System Management: Integrated Care Systems and Sustainability and Transformation Partnerships Other How to cite: Sanderson, Marie; Allen, Pauline; Osipovic, Dorota; Boiko, Olga and Lorne, Colin (2021). The Developing Architecture of System Management: Integrated Care Systems and Sustainability and Transformation Partnerships. London School of Hygiene & Tropical Medicine, London, UK.
After two and a half decades of marketization, Pauline Allen argues that the attitudes of NHS man... more After two and a half decades of marketization, Pauline Allen argues that the attitudes of NHS managers towards competition in our health services are changing. Whilst in general NHS managers remain committed to co-operation and collaboration, pockets of pro-competitive thinking are present. However, a lack of clear policy direction leaves many managers preoccupied first of all with preserving their own organisation’s interests and identities.
The version in the Kent Academic Repository may differ from the final published version. Users ar... more The version in the Kent Academic Repository may differ from the final published version. Users are advised to check http://kar.kent.ac.uk for the status of the paper. Users should always cite the published version of record.
From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary c... more 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. 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). 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. 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 provide...
Annals of Public and Cooperative Economics, Feb 7, 2011
They are designed to increase the marketlike behaviour of providers of care with a view to improv... more They are designed to increase the marketlike behaviour of providers of care with a view to improving efficiency, quality and responsiveness of services. This paper is concerned with one aspect of those reforms: namely the policy to increase the diversity of types of providers of care to NHS patients. In this context, increasing diversity means that providers will not all be standard publicly owned NHS organizations. They can be publicly owned but autonomous, or independent (both in for-profit and not for profit). The paper discusses the wide range of organizational forms available, analyzing their governance structures It then discusses the small amount of evidence currently available about the performance of diverse providers of health care.
Taking the first era from the inception of the NHS through to 1974, this chapter documents the es... more Taking the first era from the inception of the NHS through to 1974, this chapter documents the establishment of the service as a home nursing service. Known as the 'tripartite era' because of the way provision of health services were divided between three types of bodies-Local Authorities (LA), Executive Councils of the Ministry of Health and Hospital Boards-this era would see a split enshrined between LA-provided community nursing services and medical services provided by the others. This split has been a feature of the NHS ever since, despite successive unifying re-organisations of the health service, and has come to define the way community nursing is perceived by policy apparent in this review. In line with the format of the chapters, we start to look at the role and function of district nurses (DNs) and begin to see how the role was focused on home care for the sick, management of infectious diseases and supporting doctors. We also begin to examine how DNs were managed and paid for and identify the enduring tensions in how they are organised-either geographically or attached to GP practices. We conclude this chapter with a brief paragraph summing up that for this era the role of district nurse services, despite becoming a national requirement, is rarely fully set out in policy. In other words, the district nursing service was largely invisible in policy terms.
This book brings together selected research on commissioning healthcare in the English NHS carrie... more This book brings together selected research on commissioning healthcare in the English NHS carried out by national policy research unit in commissioning and the healthcare system (PRUComm) between 2011 and 2018. PRUComm is funded by the English Department of Health’s Policy Research Programme. The bookexplores the changes to commissioning in the English NHS quasi market introduced by the Health and Social Care Act 2012 (HSCA 2012). It focuses on threemain areas: first, the development and operation of the newly formed commissioning bodies named Clinical Commissioning Groups (CCGs) which were supposed to increase clinical engagement; secondly, technical aspects of commissioning being the use of competition and cooperation by CCGs to commission care in the HSCA 2012 regulatory context encouraging competition,and the allocation of financial risk through contracts between commissioners and providers of care (including new forms of contract such as alliances); and thirdly the reorganisat...
COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective e... more COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective equipment (PPE) has complex origins. This article explores the long-lasting struggle for centralisation in NHS procurement and its impact on the current PPE crisis.
Policy driven change is challenging, with a significant gap between theory and practice. A key te... more Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid lea...
Accountability is at the heart of the concept of clinical governance. Not only must health profes... more Accountability is at the heart of the concept of clinical governance. Not only must health professionals strive to improve the quality of care, they must also be able to show that they are doing so. The notion of accountability is not new-clinicians have long been accountable to their professional regulatory bodies. However, recent scandals about dangerous practice by doctors have damaged confidence in the current system of peer-led self regulation and raised concerns about the limited accountability of doctors in particular. 1 2 The new requirement for primary care clinicians to be answerable to colleagues in their practice and their primary care group or trust can be seen as one of a range of responses to these concerns and is central to the notion of clinical governance. This paper will discuss how the notion of accountability in clinical governance can be understood and operationalised within primary care. It will use the clinical governance work of a London primary care group as a case study to illustrate mechanisms of accountability and will show how there are different forms of accountability between health professionals and others, relating to various aspects of performance. The paper will also consider the barriers to improved accountability and highlight tensions that are likely to arise.
Since the beginning of the 1990s the public health care system in England has been subject to ref... more Since the beginning of the 1990s the public health care system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilising a theory of new institutionalism this paper 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 marketisation 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.
International Journal of Public and Private Healthcare Management and Economics, 2012
Preferences have been analyzed extensively in health care, but few studies have examined how cult... more Preferences have been analyzed extensively in health care, but few studies have examined how culture driven preference formation may impact on resource allocation decisions in public and private health service delivery. This paper explores and develops a theoretical framework that distinguishes different approaches to institutionally and culturally informed preferences. The analysis shows that the appropriate approach depends on normative considerations and the particular health policy context which it is applied. In particular health policy cultures, mediating culture driven preferences (such as fatalism, hierarchism, individualism, egalitarianism and autonomy) which have not been used as part of health policy analysis before, challenge the roles of public and private health service providers. In view of the scarcity of studies in this field, the authors suggest a rationale for studies that enhance the understanding of how health policy cultures are embedded in normative health pol...
In England, policy piloting has become firmly established in almost all areas of public policy an... more In England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the ex...
Continuities and changes in policy concerning the organisational structure of the British Nationa... more Continuities and changes in policy concerning the organisational structure of the British National Health Service are evident throughout the last decade. This paper presents lessons learned from the internal market experience and discusses the extent to which New Labour policies have taken these into account. The role of decentralised contracts and central government direction in each system is explored. The internal market was less decentralised than expected, and direction from central government continued to be a key element. In the post internal market system, less faith has been placed in the capacity of contracts to improve quality of care, and centralised direction to set and enforce standards has increased. But simultaneously the mechanism of contracting has been retained and it is likely to be extended in increased dealings with the private sector. Efforts are also being made to curtail the high degree of centralisation in the early post internal market years.
We investigate how the formal national provisions for pricing in the NHS (which are a form of pro... more We investigate how the formal national provisions for pricing in the NHS (which are a form of prospective payment, known as Payment by Results) are operationalised at local level. Transactions costs theory and existing evidence predict that actual practice often does not comply with contractual rules. Our 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 organisational challenges facing the NHS.
Background. GPs have to respond to conflicting policy developments. As gatekeeper they are suppos... more Background. GPs have to respond to conflicting policy developments. As gatekeeper they are supposed to manage the growing demand for specialist services and as patient advocate they should be responsive to patients' preferences. We used an innovative approach to develop a referral guideline for patients with chronic knee pain that explicitly incorporates patients' preferences. Methods. A guideline development group of 12 members including patients, GPs, orthopaedic surgeons and other health care professionals used formal consensus development informed by systematic evidence reviews. They rated the appropriateness of referral for 108 case scenarios describing patients according to symptom severity, age, body mass, co-morbidity and referral preference. Appropriateness was expressed on scale from 1 ('strongly disagree') to 9 ('strongly agree'). Results. Ratings of referral appropriateness were strongly influenced by symptom severity and patients' referral preferences. The influence of other patient characteristics was small. There was consensus that patients with severe knee symptoms who want to be referred should be referred and that patient with moderate or mild symptoms and strong preference against referral should not be referred. Referral preference had a greater impact on the ratings of referral appropriateness when symptoms were moderate or severe than when symptoms were mild. Conclusions. Referral decisions for patients with osteoarthritis of the knee should only be guided by symptom severity and patients' referral preferences. The guideline development group seemed to have given priority to avoiding inefficient resource use in patients with mild symptoms and to respecting patient autonomy in patients with severe symptoms.
Chapter 2 provides the context, setting out the organisation and governance of commissioning in t... more Chapter 2 provides the context, setting out the organisation and governance of commissioning in the NHS. It includes a short summary of the architecture of commissioning pre-Health and Social Care Act (HSCA12), and highlights the important changes which were brought about by the Act, including the abolition of Primary Care Trusts and Strategic Health Authorities, the establishment of Clinical Commissioning Groups (CCGs), the creation of NHS England, transfer of commissioning responsibilities to different bodies (e.g. public health) and the setting up of local Health and Wellbeing Boards. The chapter also highlights the programme theories underlying the HSCA12, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Li... more This is an Open Access article distributed under the terms of the Creative Commons Attribution License
The Developing Architecture of System Management: Integrated Care Systems and Sustainability and ... more The Developing Architecture of System Management: Integrated Care Systems and Sustainability and Transformation Partnerships Other How to cite: Sanderson, Marie; Allen, Pauline; Osipovic, Dorota; Boiko, Olga and Lorne, Colin (2021). The Developing Architecture of System Management: Integrated Care Systems and Sustainability and Transformation Partnerships. London School of Hygiene & Tropical Medicine, London, UK.
After two and a half decades of marketization, Pauline Allen argues that the attitudes of NHS man... more After two and a half decades of marketization, Pauline Allen argues that the attitudes of NHS managers towards competition in our health services are changing. Whilst in general NHS managers remain committed to co-operation and collaboration, pockets of pro-competitive thinking are present. However, a lack of clear policy direction leaves many managers preoccupied first of all with preserving their own organisation’s interests and identities.
The version in the Kent Academic Repository may differ from the final published version. Users ar... more The version in the Kent Academic Repository may differ from the final published version. Users are advised to check http://kar.kent.ac.uk for the status of the paper. Users should always cite the published version of record.
From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary c... more 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. 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). 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. 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 provide...
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