Primary care-led commissioning and public involvement in the English National Health Service. Lessons from the past

'It is still coming from the centre and coming out': The material conditions adding to over-bureaucratised patient and public involvement for commissioning health and care in England

OBJECTIVE

To understand how materiality affects patient and public involvement (PPI) for commissioning and leading health and care services in the English National Health Service (NHS) context.

CONTEXT

From April 2013 groups of general practitioners (GPs) became members of NHS clinical commissioning groups (CCGs) to assess needs and procure core health services for and with local communities. Since July 2022, integrated care systems (ICSs) have subsumed this responsibility. NHS reorganisations have been driven by the promise of more effective and efficient health care and have led to a long history of PPI on economic, political, and moral grounds. Few studies researching PPI in clinical commissioning exist and fewer still have explored a more agentic understanding of materiality and its impact on PPI.

STUDY DESIGN

A focused ethnography was used to examine PPI for clinical commissioning within two CCG case study sites in England. Three CCG Governing Body lay representatives, nine GP commissioners and seven service user representatives took part in focus groups and/or were interviewed. Fifteen nonparticipant observations were also carried out at CCG meetings and the associated materiality was examined.

FINDINGS

The materiality of activities involved in clinical commissioning influences and shapes the nature of PPI. These forms of materiality may dilute and subvert meaningful engagement and involvement that relies on trust, leadership, learning, and partnership working.

CONCLUSION

System leaders in ICSs should consider the significance of materiality in centrally driven processes involved in PPI commissioning to reduce barriers and ensure meaningful partnerships within local communities.

PATIENT AND PUBLIC CONTRIBUTION

The study design ensured PPI throughout the research process in keeping with contemporary research practice guidance. The project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings.

Using social media for patient and public involvement and engagement in health research: The process and impact of a closed Facebook group

BACKGROUND

As part of a multifaceted approach to patient and public involvement and engagement (PPIE), alongside traditional methods, a closed Facebook group was established to facilitate PPIE feedback on various aspects of a project that used video-recording to examine risk communication in NHS Health Checks between June 2017 and July 2019.

OBJECTIVE

To explore the process and impact of conducting PPIE through a closed Facebook group and to identify the associated benefits and challenges.

METHODS

Supported by reflections and information from project meetings used to document how this engagement informed the project, we describe the creation and maintenance of the Facebook Group and how feedback from the group members was obtained. Facebook data were used to investigate levels and types of engagement in the closed Facebook group. We reflect on the challenges of using this method of engaging the public in health research.

RESULTS

A total of 289 people joined the 'Risk Communication of Cardiovascular disease in NHS Health Checks' PPIE closed Facebook group. They provided feedback, which was used to inform aspects of the study, including participant-facing documents, recruitment, camera position and how the methodology being used (video-recorded Health Checks and follow-up interviews) would be received by the public.

DISCUSSION

Using a closed Facebook group to facilitate PPIE offered a flexible approach for both researchers and participants, enabled a more inclusive method to PPIE (compared with traditional methods) and allowed rapid feedback. Challenges included maintaining the group, which was more labour intensive than anticipated and managing members' expectations. Suggestions for best practice include clear communication about the purpose of the group, assigning a group co-ordinator to be the main point of contact for the group, and a research team who can dedicate the time necessary to maintain the group.

CONCLUSION

The use of a closed Facebook group can facilitate effective PPIE. Its flexibility can be beneficial for researchers, patients and public who wish to engage in the research process. Dedicated time for sustained group engagement is important.

PATIENT OR PUBLIC CONTRIBUTION

Patient representatives were engaged with the development of the research described in this paper and a patient representative reviewed the manuscript.

A Qualitative Exploration of Stakeholder Involvement in Decision-Making for Alcohol Treatment and Prevention Services

The concept of providing individuals with a ‘voice’ via stakeholder involvement has been advocated within English health care policy for several decades. Stakeholder involvement encourages people affected by an issue to contribute to planning and decision making regarding treatment and care, inclusive of providers and recipients of care. This paper explores stakeholder involvement in the design and delivery of public health alcohol services. A qualitative case study approach was adopted, including in-depth interviews with 11 alcohol commissioners, 10 alcohol service providers and 6 general practitioners plus three facilitated focus groups with 31 alcohol service users. Findings show that most participants were aware of, and could name, various methods of stakeholder involvement that they had engaged with; however, the extent and impact of stakeholder involvement in decision making are not transparent. It is essential that a deeper understanding is generated of the different roles that stakeholders can play within the entire decision-making process to maximise its utility.

Patient involvement at the managerial level: the effectiveness of a patient and family advisory council at a regional cancer centre in Sweden

BACKGROUND

In cancer care as well as other types of treatment and care, little is known about the contribution of Patient and Family Advisory Councils (PFACs) operating at the managerial level in healthcare organizations. The aim of the study was to investigate the effectiveness of a Swedish PFAC operating at the managerial level at one of Sweden's six regional cancer centres.

METHODS

This was a qualitative, single-case study based on interviews with PFAC participants and meeting minutes from PFAC meetings. These were analysed using a modified version of a framework developed by Abelson et al. to design and evaluate collective involvement processes in the healthcare sector: (i) representation; (ii) information; (iii) process or procedures and (iv) outcomes and decisions.

RESULTS

The descriptive representation was good regarding geographical location and cancer diagnosis. Information from the regional cancer centre was an important part of the meeting agenda. The procedures encouraged everyone to speak up, and the participants saw the representatives from the regional cancer centre as allies against the hospitals and regions, raising some questions about the PFAC's independence. Regarding outcomes, most participants did not know to what extent their work had led to any improvements in cancer care. However, they still regarded the council as effective, as issues the participants raised were listened to by the representatives from the regional cancer centre and 'taken further' in the healthcare organization.

CONCLUSIONS

The participants were satisfied with being listened to, but they found it difficult to know whether their work had led to improvements, in part because they did not know enough about how the healthcare organization worked above the care-provision level. This was a hurdle to achieving change. The study suggests it is more difficult for patients and next of kin to participate at the managerial level, compared to the care-provision level in healthcare systems, where they could potentially influence important aspects of cancer care and policy, since it is at these levels strategic decisions about priorities in cancer care and service configurations are made. This indicates that there is a particular need for guidance and support for patient and public involvement to work successfully at this level, which may include relevant education and training in system knowledge.

The impact of patient and public involvement in health research versus healthcare: A scoping review of reviews

Many policies promote patient and public involvement (PPI) in health research and healthcare provision. However, research points to uncertainties about its impact. The aim of the article was to compare what types of impact have been reported in reviews of PPI in health research and healthcare, respectively, and to map differences and similarities between the review studies. A review of reviews was undertaken with a search strategy based on the PCC mnemonic for scoping reviews. Four online databases were searched. Studies published in English between the years 2000-2020, using a review-based method and aiming to demonstrate impact of PPI were included, resulting in sixty-one articles. More reviews of PPI impact in healthcare than in health research were found, although the latter included a larger number of empirical studies. Systematic reviews, quality assessment and quantitative studies were less common in health research. Many original studies were from the United Kingdom. In health research, reported impacts most often related to research design and delivery, while in healthcare the most commonly reported impacts were individual health outcomes/clinical outcomes. However, there is still uncertainty about the strength of evidence for PPI, in particular when it comes to collective involvement in healthcare, that is in policymaking and service improvement initiatives at hospitals or the like.

Re-orienting health systems through a commissioning approach: finding solutions for improved consumer engagement

As many developed health systems grapple with the reorientation of their systems to those that are commissioning led, consumer engagement has emerged as an important theme. Despite many governments asserting the importance of consumer engagement in commissioning, an evidence base is yet to be developed to support this approach. This paper identifies the challenges and gaps in the literature relating to consumer engagement and commissioning, before setting out five potential solutions to these challenges. Ultimately, consumer engagement needs clarity of purpose and any approach should be tailored to context. Effective client involvement needs time and investment. To embark on such a process without this effort can be counterproductive.

A Hierarchy of Power: The Place of Patient and Public Involvement in Healthcare Service Development

Amidst statutory and non-statutory calls for effective patient and public involvement (PPI), questions continue to be raised about the impact of PPI in healthcare services. Stakeholders, policy makers, researchers, and members of the public ask in what ways and at what level PPI makes a difference. Patient experience is widely seen as an important and valuable resource to the development of healthcare services, yet there remain legitimacy issues concerning different forms of knowledge that members of the public and professionals bring to the table, and related power struggles. This paper draws on data from a qualitative study of PPI in a clinical commissioning group (CCG) in the UK. The study looked at some of the activities in which there was PPI; this involved researchers conducting observations of meetings, and interviews with staff and lay members who engaged in CCG PPI activities. This paper explores power imbalances when it comes to influencing the work of the CCG mainly between professionals and members of public, but also between different CCG staff members and between different groups of members of public. The authors conclude that a hierarchy of power exists, with some professionals and public and lay members afforded more scope for influencing healthcare service development than others-an approach which is reflected in the ways and extent to which different forms and holders of knowledge are viewed, managed, and utilized.

Systems levers for commissioning primary mental healthcare: a rapid review

Primary Health Networks (PHNs) are a new institution for health systems management in the Australian healthcare system. PHNs will play a key role in mental health reform through planning and commissioning primary mental health services at a regional level, specifically adopting a stepped care approach. Selected PHNs are also trialling a healthcare homes approach. Little is known about the systems levers that could be applied by PHNs to achieve these aims. A rapid review of academic and grey literature published between 2006 and 2016 was undertaken to describe the use of systems levers in commissioning primary care services. Fifty-six documents met the inclusion criteria, including twelve specific to primary mental healthcare. Twenty-six levers were identified. Referral management, contracts and tendering processes, and health information systems were identified as useful levers for implementing stepped care approaches. Location, enrolment, capitation and health information systems were identified as useful in implementing a healthcare homes approach. Other levers were relevant to overall health system functioning. Further work is needed to develop a robust evidence-base for systems levers. PHNs can facilitate this by documenting and evaluating the levers that they deploy, and making their findings available to researchers and other commissioning bodies.

Community participation in primary care: willingness to participate, a web survey in the Netherlands

Aim

The aim of the study is to explore to what extent members of the community are willing to participate in the way their primary care practice is organized and which characteristics of people and community are associated with this willingness.

Background

Community participation in primary care refers to involvement of community members in the organization, governance and policy making of primary care facilities. Due to demographic changes and changes in the role of patients and the community concerning health care, it becomes important to include the social environment of patients into healthcare. Community participation may help GPs to improving their practice and providing care according to the needs of the population. Interpreted this way, it may be an important contributor to quality of care.

Methods

In 2016, a web questionnaire was send to 800 members of the Dutch Health Care Consumer Panel. The response rate was 34%. Willingness to participate was divided into perceived readiness, ability and time to participate. The data were analysed using frequency tables and linear regression analysis.

Findings

Half of the participants were ready to give their opinion on primary care and one-third reported willingness to participate in decision making. Participants were less optimistic about their ability to participate and the time they have available for participation. Readiness and perceived ability were mainly determined by the importance that the respondents attributed to participation. Participants with previous experience in volunteering appeared more willing to spend time on participation.

Conclusions

This study showed that half of the respondents are willing to participate, but they are less sure about their ability to do so and that finding time to participate is seen as problematic. Future research should focus on which characteristics influence willingness. This knowledge might help primary care facilities to recruit people more easily and successfully.

Decision making in NICE single technological appraisals: How does NICE incorporate patient perspectives?

CONTEXT

The National Institute for Health and Care Excellence (NICE) has an explicit mandate to include patient and public involvement in the appraisal of medicines to be available for funding on the NHS. NICE involves an appraisal committee who are required to take on board experiential evidence from patient experts alongside population-based evidence on clinical and cost-effectiveness when making a decision whether to fund a drug.

OBJECTIVE

This paper considers how NICE Single Technological Appraisal (STA) committees attempt to incorporate the views of patients in making decisions about funding medicines on the NHS.

METHODS

A prospective design was employed to follow three pharmaceutical products involving three different appraisal committees. Three data collection methods were used: analysis of documentary evidence sent by NICE, non-participant unstructured observations of the open and closed sessions of meetings and qualitative interviews.

SETTINGS AND PARTICIPANTS

Unstructured non-participant observations were carried out at nine STA meetings, and 41 semi-structured interviews were undertaken with committee members from NICE's STA committees, patient experts, analysts from NICE's project team and drug manufacturers.

RESULTS

Our analysis showed how the committees displayed a preference for an ideal-type of patient representative, disagreement among the committee when weighing-up patient statements in the STA process and more pre-preparation support for patient involvement.

CONCLUSIONS

Although NICE has attempted to adopt an approach flexible to patients and carers through formal decision-making arrangements that incorporate patient views, nonetheless, the processes of the STAs can in fact undermine the very evidence collected from patient representatives.

Whose voices? Patient and public involvement in clinical commissioning

Aim

This paper aims to explore patient and public representation in a NHS clinical commissioning group and how this is experienced by staff and lay members involved.

Background

Patient and public involvement is believed to foster greater public representativeness in the development and delivery of health care services. However, there is widespread debate about what representation is or what it should be. Questions arise about the different constructions of representation and the representativeness of patients and the public in decision‐making structures and processes.

Design

Ethnographic, two‐phase study involving twenty‐four observations across two types of clinical commissioning group meetings with patient and public involvement, fourteen follow‐up interviews with NHS staff and lay members, and a focus group with five lay members.

Results

Perceptions of what constitutes legitimate representativeness varied between respondents, ranging from representing an individual patient experience to reaching large numbers of people. Consistent with previous studies, there was a lack of clarity about the role of lay members in the work of the clinical commissioning group.

Conclusions

Unlike previous studies, it was lay members, not staff, who raised concerns about their representativeness and legitimacy. Although the clinical commissioning group provides resources to support patient and public involvement, there continues to be a lack of clarity about roles and scope for impact. Lay members are still some way from constituting a powerful voice at the table.

Challenges Facing Healthwatch, a New Consumer Champion in England

This article engages with debates about the conceptualisation and practical challenges of patient and public involvement (PPI) in health and social care services. Policy in this area in England has shifted numerous times but increasingly a consumerist discourse seems to override more democratic ideas concerning the relationship between citizens and public services. Recent policy change in England has seen the creation of new consumer champion bodies in the form of local Healthwatch. The article describes these new organisational structures for PPI and shows how those who seek to influence planning and delivery of services or comment or complain about aspects of their care face considerable complexity. This is due, in part, to the ambiguous remit set out for newly instigated Healthwatch organisations by government. Drawing on governance theory, we show that it can also be understood as a function of an increasingly polycentric governance arena. Challenges that flow from this include problems of specifying jurisdictional responsibility, accountability, and legitimacy. We review Healthwatch progress to date, then we set out four challenges facing local Healthwatch organisations before discussing the implications of these for patients and the public. The first challenge relates to non-coterminous boundaries and jurisdictional integrity. Secondly, establishing the unique features of Healthwatch is problematic in the crowded PPI arena. The third challenge arises from limited resources as well as the fact that resources flow to Healthwatch from the local authorities that Healthwatch are expected to hold to account. The fourth challenge we identify is how local Healthwatch organisations negotiate the complexity of being a partner to statutory and other organisations, while at the same time being expected to champion local people's views.