Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis

OBJECTIVES

Since April 2015, Clinical Commissioning Groups (CCGs) have taken on the responsibility to commission primary care services. The aim of this paper is to analyse how CCGs have responded to this new responsibility and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems.

DESIGN

We undertook an exploratory approach, combining data from interviews and national telephone surveys, with analysis of policy documents and case studies in four CCGs. Data were analysed using thematic content analysis.

SETTING/PARTICIPANTS

We reviewed 147 CCG application documents and conducted two national telephone surveys with CCGs (n=49 and n=21). We interviewed 6 senior policymakers and 42 CCG staff who were involved in primary care co-commissioning (general practitioners and managers). We observed 74 primary care commissioning committee meetings and their subgroups (approx. 111 hours).

RESULTS

CCGs in our case studies focused their primary care commissioning activities on developing strategic plans, 'new' primary care initiatives, and dealing with legacy work. Many plans focused on incentivising and supporting practices to work together and provide a broad range of services. There was a clear focus on ensuring the sustainability of general practice. Our respondents expressed mixed views as to what new collaborative service models, such as the new models of care and sustainability and transformation partnerships (STPs), would mean for the future of primary care and the impact they could have on CCGs and their members.

CONCLUSIONS

There is a disconnect between locally based primary care and the wider system. One of the major challenges we identified is the lack of knowledge and expertise in the field of primary care at STP level. While primary care commissioning by CCGs seems to be supporting local collaborations between practices, there is some way to go before this is translated into broader integration initiatives across wider footprints.

Beyond the parish pump: what next for public health?

BACKGROUND

Public health has had a history characterised by uncertainty of purpose, locus of control, and workforce identity. In many health systems, the public health function is fragmented, isolated and under-resourced. We use the most recent major reforms to the English National Health Service and local government, the Health and Social Care Act 2012 (HSCA12), as a lens through which to explore the changing nature of public health professionalism.

METHODS

This paper is based upon a 3-year longitudinal study into the impacts of the HSCA12 upon the commissioning system in England, in which we conducted 141 interviews with 118 commissioners and senior staff from a variety of health service commissioner and provider organisations, local government, and the third sector. For the present paper, we developed a subset of data relevant to public health, and analysed it using a framework derived from the literature on public health professionalism, exploring themes identified from relevant policy documents and research.

RESULTS

The move of public health responsibilities into local government introduced an element of politicisation which challenged public health professional autonomy. There were mixed feelings about the status of public health as a specialist profession. The creation of a national public health organisation helped raise the profile of profession, but there were concerns about clarity of responsibilities, accountability, and upholding 'pure' public health professional values. There was confusion about the remit of other organisations in relation to public health.

CONCLUSIONS

Where public health professionals sit in a health system in absolute terms is less important than their ability to develop relationships, negotiate their roles, and provide expert public health influence across that system. A conflation between 'population health' and 'public health' fosters unrealistic expectations of the profession. Public health may be best placed to provide leadership for other stakeholders and professional groups working towards improving health outcomes of their defined populations, but there remains a need to clarify the role(s) that public health as a specialist profession has to play in helping to fulfil population health goals.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience

Background

Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various ‘new models of care’, including general practice offering ‘additional availability’ appointments during evenings and at weekends. In Greater Manchester, six ‘demonstrator sites’ were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes.

Methods

Semi-structured interviews, with the data subjected to thematic analysis.

Results

Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants.

Conclusions

The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

Integrated care

Purpose

The purpose of this paper is to try and understand how several organisations in one area in England are working together to develop an integrated care programme. Weick’s (1995) concept of sensemaking is used as a lens to examine how the organisations are working collaboratively and maintaining the programme.

Design/methodology/approach

Qualitative methods included: non-participant observations of meetings, interviews with key stakeholders and the collection of documents relating to the programme. These provided wider contextual information about the programme. Comprehensive field notes were taken during observations and analysed alongside interview transcriptions using NVIVO software.

Findings

This paper illustrates the importance of the construction of a shared identity across all organisations involved in the programme. Furthermore, the wider policy discourse impacted on how the programme developed and influenced how organisations worked together.

Originality/value

The role of leaders from all organisations involved in the programme was of significance to the overall development of the programme and the sustained momentum behind the programme. Leaders were able to generate a “narrative of success” to drive the programme forward. This is of particular relevance to evaluators, highlighting the importance of using multiple methods to allow researchers to probe beneath the surface of programmes to ensure that evidence moves beyond this public narrative.

Enacting localist health policy in the English NHS: the 'governing assemblage' of Clinical Commissioning Groups

Objectives The Health and Social Care Act 2012 introduced Clinical Commissioning Groups to take responsibility for commissioning (i.e. planning and purchasing) the majority of services for local populations in the English NHS. Constituted as 'membership organizations', with membership compulsory for all GP practices, Clinical Commissioning Groups are overseen by, and are accountable to, a new arm's-length body, NHS England. This paper critically engages with the content and policy narrative of the 2012 Act and explores this in relation to the reality of local policy enactment. Methods Set against a careful review of the 2012 Act, a case study of a nascent Clinical Commissioning Groups was conducted. The research included observations of Clinical Commissioning Group meetings and events (87 h), and in-depth interviews (16) with clinical commissioners, GPs, and managers. Results The 2012 Act was presented as part of a broader government agenda of decentralization and localism. Clinical Commissioning Group membership organizations were framed as a means of better meeting the needs and preferences of local patients and realizing a desirable increase in localism. The policy delineated the 'governing body' and 'the membership', with the former elected from/by the latter to oversee the organization. 'The membership' was duty bound to be 'good', engaged members and to represent their patients' interests. Fieldwork with Notchcroft Clinical Commissioning Group revealed that Clinical Commissioning Groups' statutory duty to NHS England to 'ensure the continuous improvement' of GP practice members involved performance scrutiny of GP practices. These governance processes were carried out by a varied cast of individuals, many of whom did not fit into the binary categorization of membership and governing body constructed in the policy. A concept, the governing assemblage, was developed to describe the dynamic cast of people involved in shaping the work and direction of the Clinical Commissioning Group, many of whom were unelected and of uncertain status. This was of particular significance in Notchcroft Clinical Commissioning Group because the organization explicitly pursued a governance system based on developing positions of consensus. The governing assemblage concept is valuable in articulating the actual practices of Clinical Commissioning Group governance, how these relate to the normative content of the 2012 Act, and the tensions that emerge. Conclusions The governing assemblage concept provided clarity in discussion of the dynamics of organizational governance in Notchcroft Clinical Commissioning Group, which did not follow the simple template articulated in the 2012 Act. The concept merits application in the study of other Clinical Commissioning Groups and may prove valuable in illuminating governance processes within a range of other health care organizations in different contexts. The governing assemblage holds promise for the analysis of ongoing changes to NHS organization, as well as international health care organizations such as accountable care organizations in the US.

How are clinical commissioning groups managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis

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.

How do workplaces, working practices and colleagues affect UK doctors' career decisions? A qualitative study of junior doctors' career decision making in the UK

OBJECTIVES

This study draws on an in-depth investigation of factors that influenced the career decisions of junior doctors.

SETTING

Junior doctors in the UK can choose to enter specialty training (ST) programmes within 2 years of becoming doctors. Their specialty choices contribute to shaping the balance of the future medical workforce, with views on general practice (GP) careers of particular interest because of current recruitment difficulties. This paper examines how experiences of medical work and perceptions about specialty training shape junior doctors' career decisions.

PARTICIPANTS

Twenty doctors in the second year of a Foundation Training Programme in England were recruited. Purposive sampling was used to achieve a diverse sample from respondents to an online survey.

RESULTS

Narrative interviewing techniques encouraged doctors to reflect on how experiences during medical school and in medical workplaces had influenced their preferences and perceptions of different specialties. They also spoke about personal aspirations, work priorities and their wider future.Junior doctors' decisions were informed by knowledge about the requirements of ST programmes and direct observation of the pressures under which ST doctors worked. When they encountered negative attitudes towards a specialty they had intended to choose, some became defensive while others kept silent. Achievement of an acceptable work-life balance was a central objective that could override other preferences.Events linked with specific specialties influenced doctors' attitudes towards them. For example, findings confirmed that while early, positive experiences of GP work could increase its attractiveness, negative experiences in GP settings had the opposite effect.

CONCLUSIONS

Junior doctors' preferences and perceptions about medical work are influenced by multiple intrinsic and extrinsic factors and experiences. This paper highlights the importance of understanding how perceptions are formed and preferences are developed, as a basis for generating learning and working environments that nurture students and motivate their professional careers.

Exploring the relationship between general practice characteristics and attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10-2012/2013: a longitudinal study

BACKGROUND

The UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.

METHODS

A longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients' emergency attendance rates and patients' reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.

RESULTS

Practice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (-0.26 per 1% increase, 95%CI -0.45 to -0.08).

CONCLUSION

Practices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

General practitioners' views of clinically led commissioning: cross-sectional survey in England

OBJECTIVES

Involving general practitioners (GPs) in the commissioning/purchasing of services has been an important element in English health policy for many years. The Health and Social Care Act 2012 handed responsibility for commissioning of the majority of care for local populations to GP-led Clinical Commissioning Groups (CCGs). In this paper, we explore GP attitudes to involvement in commissioning and future intentions for engagement.

DESIGN AND SETTING

Survey of a random sample of GPs across England in 2015.

METHOD

The Eighth National GP Worklife Survey was distributed to GPs in spring 2015. Responses were received from 2611 respondents (response rate = 46%). We compared responses across different GP characteristics and conducted two sample tests of proportions to identify statistically significant differences in responses across groups. We also used multivariate logistic regression to identify the characteristics associated with wanting a formal CCG role in the future.

RESULTS

While GPs generally agree that they can add value to aspects of commissioning, only a minority feel that this is an important part of their role. Many current leaders intend to quit in the next 5 years, and there is limited appetite among those not currently in a formal role to take up such a role in the future. CCGs were set up as 'membership organisations' but only a minority of respondents reported feeling that they had 'ownership' of their local CCG and these were often GPs with formal CCG roles. However, respondents generally agree that the CCG has a legitimate role in influencing the work that they do.

CONCLUSION

CCGs need to engage in active succession planning to find the next generation of GP leaders. GPs believe that CCGs have a legitimate role in influencing their work, suggesting that there may be scope for CCGs to involve GPs more fully in roles short of formal leadership.

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

OBJECTIVES

To describe how processes of primary care access influence decisions to seek help at the emergency department (ED).

DESIGN

Ethnographic case study combining non-participant observation, informal and formal interviewing.

SETTING

Six general practitioner (GP) practices located in three commissioning organisations in England.

PARTICIPANTS AND METHODS

Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29).

RESULTS

Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use.

CONCLUSIONS

This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS

In spite of their widespread use in policy making in the UK and elsewhere, there is a relatively sparse literature specifically devoted to policy pilots. Recent research on policy piloting has focused on the role of pilots in making policy work in accordance with national agendas. Taking this as a point of departure, the present paper develops the notion of pilots doing policy work. It does this by situating piloting within established theories of policy formulation and implementation, and illustrating using an empirical case. Our case is drawn from a qualitative policy ethnography of a local government pilot programme aiming to extend access to healthcare services. Our case explores the collective entrepreneurship of regional policy makers together with local pilot volunteers. We argue that pilots work to mobilise and manage the ambiguity and conflict associated with particular policy goals, and in their structure and design, shape action towards particular outcomes. We conclude with a discussion of the generative but managed role which piloting affords to local implementers.

Stick or twist? Career decision-making during contractual uncertainty for NHS junior doctors

OBJECTIVES

To examine the extent, and nature, of impact on junior doctors' career decisions, of a proposed new contract and the uncertainty surrounding it.

DESIGN

Mixed methods. Online survey exploring: doctors' future training intentions; their preferred specialty training (ST) programmes; whether they intended to proceed immediately to ST; and other plans. Linked qualitative interviews to explore more fully how and why decisions were affected.

SETTING

Doctors (F2s) in second year of Foundation School (FS) Programmes in England.

PARTICIPANTS

Invitations sent by FSs. Open to all F2s November 2015-February 2016. All FSs represented. Survey completed by 816 F2s. Sample characteristics broadly similar to national F2 cohort.

MAIN OUTCOME MEASURES

Proportions of doctors intending to proceed to ST posts in the UK, to defer or to exit UK medicine. Proportion of doctors indicating changes in training and career plans as a result of the contract and/or resulting uncertainty. Distribution of changes across training programmes. Explanations of these intentions from interviews and free text comments.

RESULTS

Among the responding junior doctors, 20% indicated that issues related to the contract had prompted them to switch specialty and a further 20% had become uncertain about switching specialty. Switching specialty choice was more prevalent among those now choosing a community-based, rather than hospital-based specialty. 30% selecting general practice had switched choice because of the new contract. Interview data suggests that doctors felt they had become less valued or appreciated in the National Health Service and in society more broadly.

CONCLUSIONS

Doctors reported that contract-related issues have affected their career plans. The most notable effect is a move away from acute to community-based specialities, with the former perceived as more negatively affected by the proposed changes. It is concerning that young doctors feel undervalued, and this requires further investigation.

Integrated care: theory to practice

'Integrated care' is pitched as the solution to current health system challenges. In the literature, what integrated care actually involves is complex and contested. Multi-disciplinary team case management is frequently the primary focus of integrated care when implemented internationally. We examine the practical application of integrated care in the NHS in England to exemplify the prevalence of the case management focus. We look at the evidence for effectiveness of multi-disciplinary team case management, for the focus on high-risk groups and for integrated care more generally. We suggest realistic expectations of what integration of care alone can achieve and additional research questions.

Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

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.

Exploring the relationship between general practice characteristics, and attendance at walk-in centres, minor injuries units and EDs in England 2012/2013: a cross-sectional study

BACKGROUND

For several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance.

METHODS

We used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics.

RESULTS

Every percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates.

CONCLUSIONS

Improving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance.

Effectiveness of multidisciplinary team case management: difference-in-differences analysis

OBJECTIVES

To evaluate a multidisciplinary team (MDT) case management intervention, at the individual (direct effects of intervention) and practice levels (potential spillover effects).

DESIGN

Difference-in-differences design with multiple intervention start dates, analysing hospital admissions data. In secondary analyses, we stratified individual-level results by risk score.

SETTING

Single clinical commissioning group (CCG) in the UK's National Health Service (NHS).

PARTICIPANTS

At the individual level, we matched 2049 intervention patients using propensity scoring one-to-one with control patients. At the practice level, 30 practices were compared using a natural experiment through staged implementation.

INTERVENTION

Practice Integrated Care Teams (PICTs), using MDT case management of high-risk patients together with a summary record of care versus usual care.

DIRECT AND INDIRECT OUTCOME MEASURES

Primary measures of intervention effects were accident and emergency (A&E) visits; inpatient non-elective stays, 30-day re-admissions; inpatient elective stays; outpatient visits; and admissions for ambulatory care sensitive conditions. Secondary measures included inpatient length of stay; total cost of secondary care services; and patient satisfaction (at the practice level only).

RESULTS

At the individual level, we found slight, clinically trivial increases in inpatient non-elective admissions (+0.01 admissions per patient per month; 95% CI 0.00 to 0.01. Effect size (ES): 0.02) and 30-day re-admissions (+0.00; 0.00 to 0.01. ES: 0.03). We found no indication that highest risk patients benefitted more from the intervention. At the practice level, we found a small decrease in inpatient non-elective admissions (-0.63 admissions per 1000 patients per month; -1.17 to -0.09. ES: -0.24). However, this result did not withstand a robustness check; the estimate may have absorbed some differences in underlying practice trends.

CONCLUSIONS

The intervention does not meet its primary aim, and the clinical significance and cost-effectiveness of these small practice-level effects is debatable. There is an ongoing need to develop effective ways to reduce unnecessary attendances in secondary care for the high-risk population.

Leadership for health commissioning in the new NHS

PURPOSE

The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a "clinically-led" system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for "great leaders".

DESIGN/METHODOLOGY/APPROACH

Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed.

FINDINGS

The authors found evidence of two identified approaches to leadership - positive deviancy and responsible guardianship - being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to "do things differently" to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs' performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership.

ORIGINALITY/VALUE

This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles.

Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis.

METHODS AND FINDINGS

We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care.

CONCLUSIONS

This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future.

REVIEW PROTOCOL

The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).

What happens when GPs engage in commissioning? Two decades of experience in the English NHS

OBJECTIVE

To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere.

METHODS

A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed.

RESULTS

The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with 'virtuous cycles' (experience of being able to make changes feeding back to encourage greater engagement) and 'vicious cycles' (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues.

CONCLUSION

Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.