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Barnard R, Spooner S, Hubmann M, Checkland K, Campbell J, Swinglehurst D. The hidden work of general practitioners: An ethnography. Soc Sci Med 2024; 350:116922. [PMID: 38713977 DOI: 10.1016/j.socscimed.2024.116922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/09/2024]
Abstract
High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.
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Affiliation(s)
- Rachel Barnard
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Sharon Spooner
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Michaela Hubmann
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Checkland
- Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Campbell
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Deborah Swinglehurst
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
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Warwick-Giles L, Hutchinson J, Checkland K, Hammond J, Bramwell D, Bailey S, Sutton M. Exploring whether primary care networks can contribute to the national goal of reducing health inequalities: a mixed-methods study. Br J Gen Pract 2024; 74:e290-e299. [PMID: 38164529 PMCID: PMC11060797 DOI: 10.3399/bjgp.2023.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities. AIM To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities. DESIGN AND SETTING A sequential mixed-methods study of PCNs in England. METHOD Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019-2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020-March 2022). RESULTS Across 1243 networks in 2019-2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022-2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally. CONCLUSION Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.
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Affiliation(s)
- Lynsey Warwick-Giles
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Joseph Hutchinson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Donna Bramwell
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury
| | - Matt Sutton
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Bramwell D, Hammond J, Warwick-Giles L, Bailey S, Checkland K. Implementing the Additional Roles Reimbursement Scheme in seven English Primary Care Networks: a qualitative study. Br J Gen Pract 2024; 74:e323-e329. [PMID: 38164533 PMCID: PMC11044018 DOI: 10.3399/bjgp.2023.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The Additional Roles Reimbursement Scheme (ARRS) provides funding to Primary Care Networks (PCNs) in England to recruit additional staff into specified roles. The intention was to support general practice by recruiting an extra 26 000 staff by 2024, increasing access and easing workload pressures. AIM To explore the establishment of the ARRS as part of PCNs' development to understand their role in supporting general practice. DESIGN AND SETTING A longitudinal, qualitative case study involving seven geographically dispersed PCNs across England. METHOD Data were collected from July 2020 to March 2022, including 91 semi-structured interviews and 87 h of meeting observations. Transcripts were analysed using the framework approach. RESULTS Implementation of the ARRS was variable across the study sites, but most shared similar experiences and concerns. The COVID-19 pandemic had a significant impact on the introduction of the new roles, and significant variability was found in modes of employment. Cross-cutting issues included: the need for additional space to accommodate new staff; the inflexibility of aspects of the scheme, including reinvestment of unspent funds; and the need for support and oversight of employed staff. Perceived benefits of the ARRS include improved patient care and the potential to save GP time. CONCLUSION The findings suggest the ARRS has potential to fulfil its objective of supporting and improving access to general practice. However, attention to operational requirements including appropriate funding, estates, and management of staff is important if this is to be realised, as is clarity for the scheme post-contract end in 2024.
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Affiliation(s)
- Donna Bramwell
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Lynsey Warwick-Giles
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, Kent
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Goff M, Jacobs S, Hammond J, Hindi A, Checkland K. Investigating the impact of primary care networks on continuity of care in English general practice: Analysis of interviews with patients and clinicians from a mixed methods study. Health Expect 2024; 27:e14032. [PMID: 38556844 PMCID: PMC10982586 DOI: 10.1111/hex.14032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION In England, primary care networks (PCNs) offer opportunities to improve access to and sustainability of general practice through collaboration between groups of practices to provide care with a broader range of practitioner roles. However, there are concerns that these changes may undermine continuity of care. Our study investigates what the organisational shift to PCNs means for continuity of care. METHODS The paper uses thematic analysis of qualitative data from interviews with general practitioners and other healthcare professionals (HCPs, n = 33) in 19 practices in five PCNs, and their patients (n = 35). Three patient cohorts within each participating practice were recruited, based on anticipated higher or lower needs for continuity of care: patients over 65 years with polypharmacy, patients with anxiety or depression and 'working age' adults aged between 18 and 45 years. FINDINGS Patients and clinicians perceived changes to continuity in PCNs in our study. Larger-scale care provision in PCNs required better care coordination and information-sharing processes, aimed at improving care for 'vulnerable' patients in target groups. However, new working arrangements and ways of delivering care in PCNs undermine HCPs' ability to maintain continuity through ongoing relationships with patients. Patients experience this in terms of reduced availability of their preferred clinician, inefficiencies in care and unfamiliarity of new staff, roles and processes. CONCLUSIONS New practitioners need to be effectively integrated to support effective team-based care. However, for patients, especially those not deemed 'vulnerable', this may not be sufficient to counter the loss of relationship with their practice. Therefore, caution is required in relation to designating patients as in need of, or not in need of continuity. Rather, continuity for all patients could be maintained through a dynamic understanding of the need for it as fluctuating and situational and by supporting clinicians to provide follow-up care. PATIENT AND PUBLIC INVOLVEMENT (PPI) A PPI group was recruited and consulted during the study for feedback on the study design, recruitment materials and interpretation of findings.
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Affiliation(s)
- Mhorag Goff
- Centre for Primary CareThe University of ManchesterManchesterUK
| | - Sally Jacobs
- Centre for Primary CareThe University of ManchesterManchesterUK
| | | | - Ali Hindi
- Centre for Primary CareThe University of ManchesterManchesterUK
| | - Kath Checkland
- Centre for Primary CareThe University of ManchesterManchesterUK
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Voorhees J, Bailey S, Waterman H, Checkland K. A paradox of problems in accessing general practice: a qualitative participatory case study. Br J Gen Pract 2024; 74:e104-e112. [PMID: 38253550 PMCID: PMC10824332 DOI: 10.3399/bjgp.2023.0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/10/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity. AIM To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access. DESIGN AND SETTING A qualitative participatory case study in an area of northwest England. METHOD A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al's theory of access, allowed the team to identify complexities and relationships between interrelated problems. RESULTS This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities. CONCLUSION Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.
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Affiliation(s)
- Jennifer Voorhees
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Kent
| | - Heather Waterman
- Formerly School of Healthcare Sciences, Cardiff University, Cardiff
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Dalgarno E, McDermott I, Goff M, Spooner S, McBride A, Hodgson D, Donnelly A, Hogg J, Checkland K. The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care. J Public Health (Oxf) 2023; 45:i54-i62. [PMID: 38127564 PMCID: PMC10734673 DOI: 10.1093/pubmed/fdad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/19/2023] [Accepted: 09/28/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. METHODS We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. RESULTS Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. CONCLUSIONS While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.
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Affiliation(s)
- Elizabeth Dalgarno
- Department of Public Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PT, UK
| | - Imelda McDermott
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
| | - Mhorag Goff
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
| | - Sharon Spooner
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
| | - Anne McBride
- Institute of Health Policy and Management, Alliance Manchester Business School, University of Manchester, Manchester M13 9PT, UK
| | - Damian Hodgson
- The University of Sheffield, Management School, Sheffield, South Yorkshire, S10 2JA, UK
| | - Ailsa Donnelly
- The patient and public involvement and engagement group at The Centre for Primary Care and Health Services Research (Primer), The University of Manchester, Manchester, M13 9PL, UK
| | - Judith Hogg
- The patient and public involvement and engagement group at The Centre for Primary Care and Health Services Research (Primer), The University of Manchester, Manchester, M13 9PL, UK
| | - Kath Checkland
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
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Checkland K, Bramwell D, Warwick-Giles L, Bailey S, Hammond J. Primary care networks as a means of supporting primary care: findings from qualitative case study-based evaluation in the English NHS. BMJ Open 2023; 13:e075111. [PMID: 37989389 PMCID: PMC10668191 DOI: 10.1136/bmjopen-2023-075111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate primary care networks (PCNs) in the English National Health Service. We ask: How are PCNs constituted to meet their defined goals? What factors can be discerned as affecting their ability to deliver benefits to the community, the network as a whole and individual members? What outcomes or outputs are associated with PCNs so far? We draw policy lessons for PCN design and oversight, and consider the utility of the chosen evaluative framework. DESIGN AND SETTING Qualitative case studies in seven PCN in England, chosen for maximum variety around geography, rurality and population deprivation. Study took place between May 2019 and December 2022. PARTICIPANTS PCN members, staff employed in additional roles and local managers. Ninety-one semistructured interviews and approximately 87 hours of observations were undertaken remotely. Interview transcripts and observational field notes were analysed together using a framework approach. Initial codes were derived from our evaluation framework, with inductive coding of new concepts during the analysis. RESULTS PCNs have been successfully established across England, with considerable variation in structure and operation. Progress is variable, with a number of factors affecting this. Good managerial support was helpful for PCN development. The requirement to work together to meet the specific threat of the global pandemic did, in many cases, generate a virtuous cycle by which the experience of working together built trust and legitimacy. The internal dynamics of networks require attention. Pre-existing strong relationships provided a significant advantage. While policy cannot legislate to create such relationships, awareness of their presence/absence is important. CONCLUSIONS Networked approaches to service delivery are popular in many health systems. Our use of an explicit evaluation framework supports the extrapolation of our findings to networks elsewhere. We found the framework to be useful in structuring our study but suggest some modifications for future use.
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Affiliation(s)
- Kath Checkland
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Donna Bramwell
- School of Health Sciences, The University of Manchester, Manchester, UK
| | | | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Jonathan Hammond
- School of Health Sciences, The University of Manchester, Manchester, UK
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Hutchinson J, Lau YS, Sutton M, Checkland K. How new clinical roles in primary care impact on equitable distribution of workforce: a retrospective study. Br J Gen Pract 2023; 73:e659-e666. [PMID: 37604700 PMCID: PMC10471141 DOI: 10.3399/bjgp.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND There are inequalities in the geographical distribution of the primary care workforce in England. Primary care networks (PCNs), and the associated Additional Roles Reimbursement Scheme (ARRS) funding, have stimulated employment of new healthcare roles. However, it is not clear whether this will impact inequalities. AIM To examine whether the ARRS impacted inequality in the distribution of the primary care workforce. DESIGN AND SETTING A retrospective before-and-after study of English PCNs in 2019 and 2022. METHOD The study combined workforce, population, and deprivation data at network level for March 2019 and March 2022. The change was estimated between 2019 and 2022 in the slope index of inequality (SII) across deprivation of full-time equivalent (FTE) GPs (total doctors, qualified GPs, and doctors-in-training), nurses, direct patient care, administrative, ARRS and non- ARRS, and total staff per 10 000 patients. RESULTS A total of 1255 networks were included. Nurses and qualified GPs decreased in number while all other staff roles increased, with ARRS staff having the greatest increase. There was a pro- rich change in the SII for administrative staff (-0.482, 95% confidence interval [CI] = -0.841 to -0.122, P<0.01) and a pro- poor change for doctors-in-training (0.161, 95% CI = 0.049 to 0.274, P<0.01). Changes in distribution of all other staff types were not statistically significant. CONCLUSION Between 2019 and 2022 the distribution of administrative staff became less pro-poor, and doctors-in-training became pro-poor. The changes in inequality in all other staff groups were mixed. The introduction of PCNs has not substantially changed the longstanding inequalities in the geographical distribution of the primary care workforce.
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Affiliation(s)
- Joseph Hutchinson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Yiu-Shing Lau
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Matt Sutton
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Checkland K. Books: Hags: the Demonisation of Middle-Aged Women: Patriarchy, Power, and Older Women. Br J Gen Pract 2023; 73:321. [PMID: 37385774 PMCID: PMC10325593 DOI: 10.3399/bjgp23x733425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Affiliation(s)
- Kath Checkland
- Kath is a GP and Professor of Health Policy and Primary Care at the University of Manchester. @khcheck
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Affiliation(s)
- Kath Checkland
- School of Health Sciences, University of Manchester, Manchester, UK
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MacInnes J, Billings J, Coleman A, Mikelyte R, Croke S, Allen P, Checkland K. Scale and spread of innovation in health and social care: Insights from the evaluation of the New Care Model/Vanguard programme in England. J Health Serv Res Policy 2023; 28:128-137. [PMID: 36631723 DOI: 10.1177/13558196221139548] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up. METHODS We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation. RESULTS A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models. CONCLUSIONS This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.
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Affiliation(s)
- Julie MacInnes
- Centre for Health Services Studies, 2240University of Kent, Canterbury, Kent, UK
| | - Jenny Billings
- Centre for Health Services Studies, 2240University of Kent, Canterbury, Kent, UK
| | - Anna Coleman
- Division of Population Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Rasa Mikelyte
- Centre for Health Services Studies, 2240University of Kent, Canterbury, Kent, UK
| | - Sarah Croke
- Division of Population Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Pauline Allen
- London School of Hygiene & Tropical Medicine, Health Services Research Unit, London, UK
| | - Kath Checkland
- Division of Population Health, School of Health Sciences, University of Manchester, Manchester, UK
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Britteon P, Fatimah A, Lau YS, Anselmi L, Turner AJ, Gillibrand S, Wilson P, Checkland K, Sutton M. The effect of devolution on health: a generalised synthetic control analysis of Greater Manchester, England. The Lancet Public Health 2022; 7:e844-e852. [DOI: 10.1016/s2468-2667(22)00198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 10/14/2022] Open
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Bramwell D, Hotham S, Peckham S, Checkland K, Forbes LJL. Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation. BMJ Open Qual 2022; 11:bmjoq-2022-001960. [PMID: 36162934 PMCID: PMC9516148 DOI: 10.1136/bmjoq-2022-001960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background A 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme. Objectives To conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme. Methods Semistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews. Results Participants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas. Conclusion Practices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.
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Affiliation(s)
- Donna Bramwell
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
| | - Sarah Hotham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
- Department of Health Services and Policy Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
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Coleman A, MacInnes JD, Mikelyte R, Croke S, Allen PW, Checkland K. What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England. J Health Organ Manag 2022; ahead-of-print. [PMID: 35976876 DOI: 10.1108/jhom-02-2022-0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The article aims to argue that the concept of "distributed leadership" lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the "Strategic Action Field Framework" (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar. DESIGN/METHODOLOGY/APPROACH Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019. FINDINGS While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting. ORIGINALITY/VALUE The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of "social skills" required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.
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Affiliation(s)
- Anna Coleman
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Julie D MacInnes
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Rasa Mikelyte
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Sarah Croke
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Pauline W Allen
- Department of Health Services Research and Policy, London School of Hygiene, London, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
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Parisi R, Lau YS, Bower P, Checkland K, Rubery J, Sutton M, Giles SJ, Esmail A, Spooner S, Kontopantelis E. Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019. BMJ Open 2021; 11:e049827. [PMID: 34420932 PMCID: PMC8362689 DOI: 10.1136/bmjopen-2021-049827] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To quantify general practitioners' (GPs') turnover in England between 2007 and 2019, describe trends over time, regional differences and associations with social deprivation or other practice characteristics. DESIGN A retrospective study of annual cross-sectional data. SETTING All general practices in England (8085 in 2007, 6598 in 2019). METHODS We calculated turnover rates, defined as the proportion of GPs leaving a practice. Rates and their median, 25th and 75th percentiles were calculated by year and region. The proportion of practices with persistent high turnover (>10%) over consecutive years were also calculated. A negative binomial regression model assessed the association between turnover and social deprivation or other practice characteristics. RESULTS Turnover rates increased over time. The 75th percentile in 2009 was 11%, but increased to 14% in 2019. The highest turnover rate was observed in 2013-2014, corresponding to the 75th percentile of 18.2%. Over time, regions experienced increases in turnover rates, although it varied across English regions. The proportion of practices with high (10% to 40%) turnover within a year almost doubled from 14% in 2009 to 27% in 2019. A rise in the number of practices with persistent high turnover (>10%) for at least three consecutive years was also observed, from 2.7% (2.3%-3.1%) in 2007 to 6.3% (5.7%-6.9%) in 2017. The statistical analyses revealed that practice-area deprivation was moderately associated with turnover rate, with practices in the most deprived area having higher turnover rates compared with practices in the least deprived areas (incidence rate ratios 1.09; 95% CI 1.06 to 1.13). CONCLUSIONS GP turnover has increased in the last decade nationally, with regional variability. Greater attention to GP turnover is needed, in the most deprived areas in particular, where GPs often need to deal with more complex health needs. There is a large cost associated with GP turnover and practices with very high persistent turnover need to be further researched, and the causes behind this identified, to allow support strategies and policies to be developed.
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Affiliation(s)
- Rosa Parisi
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Yiu-Shing Lau
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Kath Checkland
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Jill Rubery
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Sally J Giles
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
| | - Aneez Esmail
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Sharon Spooner
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- Health Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, The University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
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Kislov R, Checkland K, Wilson PM, Howard SJ. 'Real-world' priority setting for service improvement in English primary care: a decentred approach. Public Manag Rev 2021; 25:150-174. [PMID: 36624816 PMCID: PMC9821632 DOI: 10.1080/14719037.2021.1942534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
This article develops an analysis of population-level priority setting informed by Bevir's decentred theory of governance and drawing on a qualitative study of priority setting for service improvement conducted in the complex multi-layered governance context of English primary care. We show how powerful actors, operating at the meso-level, utilize pluralistic and contradictory elements of complex governance networks to discursively construct, legitimize and enact service improvement priorities. Our analysis highlights the role of situated agency in integrating top-down, bottom-up and horizontal influences on priority setting, which leads to variation in local priorities despite the continuous presence of strong hierarchical influences.
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Affiliation(s)
- Roman Kislov
- Business School, Manchester Metropolitan University, Manchester, UK
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Kath Checkland
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Paul M. Wilson
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Susan J. Howard
- National Institute for Health Research Applied Research Collaboration Greater Manchester, Health Innovation Manchester, Manchester, UK
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Wilson P, Billings J, MacInnes J, Mikelyte R, Welch E, Checkland K. Investigating the nature and quality of locally commissioned evaluations of the NHS Vanguard programme: an evidence synthesis. Health Res Policy Syst 2021; 19:63. [PMID: 33845858 PMCID: PMC8042862 DOI: 10.1186/s12961-021-00711-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 03/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND With innovation in service delivery increasingly viewed as crucial to the long-term sustainability of health systems, NHS England launched an ambitious new model of care (Vanguard) programme in 2015. Supported by a £350 million transformation fund, 50 Vanguard sites were to act as pilots for innovation in service delivery, to move quickly to change the way that services were delivered, breaking down barriers between sectors and improving the coordination and delivery of care. METHODS As part of a national evaluation of the Vanguard programme, we conducted an evidence synthesis to assess the nature and quality of locally commissioned evaluations. With access to a secure, online hub used by the Vanguard and other integrated care initiatives, two researchers retrieved any documents from a locally commissioned evaluation for inclusion. All identified documents were downloaded and logged, and details of the evaluators, questions, methodological approaches and limitations in design and/or reporting were extracted. As included evaluations varied in nature and type, a narrative synthesis was undertaken. RESULTS We identified a total of 115 separate reports relating to the locally commissioned evaluations. Five prominent issues relating to evaluation conduct were identified across included reports: use of logic models, number and type of evaluation questions posed, data sharing and information governance, methodological challenges and evaluation reporting in general. A combination of resource, data and time constraints means that evaluations often attempted to but did not fully address the wide range of questions posed by individual Vanguards. CONCLUSIONS Significant investment was made in independent local evaluations of the Vanguard programme by NHS England. This synthesis represents the only comprehensive attempt to capture methodological learning and may serve as a key resource for researchers and policy-makers seeking to understand investigating large-scale system change, both within the NHS and internationally. PROSPERO (Registration number: CRD42017069282).
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Affiliation(s)
- Paul Wilson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Jenny Billings
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Julie MacInnes
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Rasa Mikelyte
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Elizabeth Welch
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Parkinson B, Meacock R, Checkland K, Sutton M. How sensitive are avoidable emergency department attendances to primary care quality? Retrospective observational study. BMJ Qual Saf 2020; 30:884-892. [PMID: 33144351 PMCID: PMC8543208 DOI: 10.1136/bmjqs-2020-011651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/04/2022]
Abstract
Background Improvements in primary care quality are often proposed as a solution to rises in emergency department (ED) attendances. However, there is little agreement on what constitutes an avoidable attendance, and the relationship between primary care quality and ED demand remains poorly understood. Objective To estimate the size of the associations between primary care quality and volumes of ED attendances classified as avoidable. Methods Retrospective observational study of all attendances at EDs in England during 2015/2016, applying three definitions of avoidable attendance. We linked practice-level counts of attendances to seven measures of primary care access, patient experience and clinical quality for 7521 practices. We used count data regressions to associate attendance counts with levels of quality. We then calculated proportions of attendances associated with levels of primary care quality below the national average. Results Attendance volumes were negatively related to three of the seven quality measures. Incidence rate ratios (IRRs) for all attendances associated with 10 percentage-point differences in quality were 0.987 for clinical quality and 0.987 for easy telephone access and 0.978 for ability to get an appointment. These associations were relatively stronger for narrower definitions of avoidable attendances (for the narrowest definition, IRRs=0.966, 0.976 and 0.934, respectively) but represented fewer attendances in absolute terms. 341 000 (2.4%) attendances were associated with levels of primary care quality below the national average in 2015/2016. Conclusion ED attendances are sensitive to primary care quality, but magnitudes of these associations are small. Attendances are much less responsive to differences in primary care quality than indicated by estimates of the prevalence of avoidable attendances. This may explain the failure of initiatives to reduce attendances through primary care improvements.
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Affiliation(s)
- Beth Parkinson
- Health, Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, University of Manchester, Manchester, Greater Manchester, UK
| | - Rachel Meacock
- Health, Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, University of Manchester, Manchester, Greater Manchester, UK
| | - Kath Checkland
- Health, Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, University of Manchester, Manchester, Greater Manchester, UK
| | - Matt Sutton
- Health, Organisation, Policy and Economics (HOPE) Group, Centre for Primary Care & Health Services Research, University of Manchester, Manchester, Greater Manchester, UK.,Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, The University of Melbourne, Parkville, Victoria, Australia
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Hayes H, Gibson J, Fitzpatrick B, Checkland K, Guthrie B, Sutton M, Gillies J, Mercer SW. Working lives of GPs in Scotland and England: cross-sectional analysis of national surveys. BMJ Open 2020; 10:e042236. [PMID: 33127639 PMCID: PMC7604859 DOI: 10.1136/bmjopen-2020-042236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced. DESIGN AND SETTING Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation. PARTICIPANTS 2048 GPs in Scotland and 879 GPs in England. MAIN OUTCOME MEASURES Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree'). RESULTS Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes. CONCLUSION Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.
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Affiliation(s)
- Helen Hayes
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jonathan Gibson
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | | | - Kath Checkland
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics Research Group, Centre for Primary Care & Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Gillies
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Stewart W Mercer
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
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Abstract
PurposeWe trace the evolution of a new integrated care policy in the English NHS (enhanced health in care homes, EHCH) from pilot model to wider roll out, over a 4-year period, into the circumstances of COVID-19.Design/methodology/approachUsing published evidence and official documentation we compared and contrasted the original EHCH model/framework, subsequent draft specifications and the final proposals, ahead of implementation.FindingsThe Primary Care Network EHCH service specification has clearly arisen from the Vanguard programme; however, problems related to GP contracts and COVID-19 means, at least initially, there is likely to be some variability over who will be responsible for delivery. It is unknown whether this service, delivered at pace in the current circumstances, will achieve or affect the outcomes envisaged by the pilots.Research limitations/implicationsThis is our interpretation of the developing policy for enhanced health in care homes, which requires further follow-up research. We are beginning our final fieldwork phase in Summer 2020, to report on the Vanguard legacy.Practical implicationsEvaluations of policy success/failure should consider the context and the differing power relations that are present and may impact subsequent take-up and roll-out across the system. We recommend a longitudinal approach to enable a holistic view of policy implementation.Originality/valueThis paper reveals the fragility of health and care policymaking in the current climate. From initial concept, through development and testing, into forced early roll out, our observations reflect the unique impact of a global pandemic shock.
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Abstract
OBJECTIVES English general practice is suffering a workforce crisis, with general practitioners retiring early and trainees reluctant to enter the profession. To address this, additional funding has been offered, but only through participation in collaborations known as primary care networks (PCNs). This study explored national policy objectives underpinning PCNs and the mechanisms expected to help achieve these, from the perspective of those driving the policy. DESIGN Qualitative semistructured interviews and policy document analysis. SETTING AND PARTICIPANTS National-level policy maker and stakeholder interviewees (n=16). Policy document analysis of the Network Contract Direct Enhanced Service draft service specifications. ANALYSIS Interviews were transcribed, coded and organised thematically according to policy objectives and mechanisms. Thematic data were organised into a matrix so prominent elements can be identified and emphasised accordingly. Themes were considered alongside objectives embedded in PCN draft service delivery requirements. RESULTS Three themes of policy objectives and associated mechanisms were identified: (1) supporting general practice, (2) place-based interorganisational collaboration and (3) primary care 'voice'. Interviewees emphasised and sequenced themes differently, suggesting meeting objectives for one was necessary to realise another. Interviewees most closely linked to primary care emphasised the importance of theme 1. The objectives embedded in draft service delivery requirements primarily emphasised theme 2. CONCLUSIONS These policy objectives are not mutually exclusive but may imply different approaches to prioritising investment or necessitate more explicit temporal sequencing, with the stabilisation of a struggling primary care sector probably needing to occur before meaningful engagement with other community service providers can be achieved or a 'collective voice' is agreed. Multiple objectives create space for stakeholders to feel dissatisfied when implementation details do not match expectations, as the negative reaction to draft service delivery requirements illustrates. Our study offers policy makers suggestions about how confidence in the policy might be restored by crafting delivery requirements so all groups see opportunities to meet favoured objectives.
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Affiliation(s)
- Kath Checkland
- Division of Population Health, Health Services Research, and Primary Care; School of Health Sciences; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jonathan Hammond
- Division of Population Health, Health Services Research, and Primary Care; School of Health Sciences; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research, and Primary Care; School of Health Sciences; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
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Osipovič D, Allen P, Sanderson M, Moran V, Checkland K. The regulation of competition and procurement in the National Health Service 2015-2018: enduring hierarchical control and the limits of juridification. Health Econ Policy Law 2020; 15:308-324. [PMID: 31488231 PMCID: PMC7525100 DOI: 10.1017/s1744133119000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/03/2019] [Accepted: 06/16/2019] [Indexed: 11/17/2022]
Abstract
Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as 'juridification'). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.
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Affiliation(s)
- Dorota Osipovič
- Department of Health Services Research and Policy, LSHTM, London, UK
| | - Pauline Allen
- Department of Health Services Research and Policy, LSHTM, London, UK
| | - Marie Sanderson
- Department of Health Services Research and Policy, LSHTM, London, UK
| | - Valerie Moran
- Luxembourg Institute of Socio-Economic Research, Esch-sur-Alzette, Luxembourg
| | - Kath Checkland
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
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McDonald R, Riste L, Bailey S, Bradley F, Hammond J, Spooner S, Elvey R, Checkland K. The impacts of GP federations in England on practices and on health and social care interfaces: four case studies. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
General practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form.
Objectives
The aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders.
Design
This was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis.
Results
All federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims. We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the requirements to provide additional services as part of NHS Improving Access to General Practice policy in a way that would not have been possible in the absence of federations. However, this added to pressures faced by busy clinicians and managers.
Limitations
The focus was on only four sites; therefore, any federations that were more active than those federations in these four sites will have been excluded. In addition, although patients were interviewed, because most were unaware of federations, they generally had little to say on the subject.
Conclusions
General practices working collaboratively can produce benefits, but this takes time and effort. The approach of the federation central authority (authoritative, indulgent or neglectful) was hugely influential in affecting processes and outcomes. However, progress was generally slower than anticipated, and negligible in one case.
Future work
Future work would benefit from multimethod designs, which provide in-depth, longitudinal, qualitative and quantitative methods, to shed light on processes and impacts.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Lisa Riste
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Fay Bradley
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Sharon Spooner
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Rebecca Elvey
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Warwick-Giles L, McDermott I, Checkland K, Moran V. Moving towards strategic commissioning: impact on clinical commissioning groups as membership organizations. J Health Serv Res Policy 2019; 25:22-29. [PMID: 30991844 DOI: 10.1177/1355819619842272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This paper aims to explore the nature of clinical commissioning groups (CCGs) in England as membership organizations. Utilizing the concept of meta-organization as a lens, we discuss the impact that this organizational form might have on CCGs’ ability to become ‘strategic commissioners’. Methods We used a longitudinal qualitative approach to explore the adoption and implementation of primary care co-commissioning. The study was undertaken between May 2015 and June 2017 and included interviews with senior policy makers, analysis of policy documents, two telephone surveys, and case studies in four CCGs nationally. Results CCGs operate as membership organizations with closed boundary and low stratification, whereby a consensus or majority needs to be reached by members when activities impact on membership or the CCG’s constitution. While CCGs should move towards a more strategic commissioning role that is focused on local priorities agreed by their members, they are faced with a complex system of accountabilities and responsibilities, which makes this difficult to achieve. Conclusions The nature of CCGs as membership-based meta-organizations has the potential to both help and hinder CCGs in becoming strategic commissioners. The complexities in accountability and governance that the membership approach introduces, and the potential difficulties that CCGs face with competing meta-organizations, raises questions about the future of CCGs as membership organizations.
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Affiliation(s)
- Lynsey Warwick-Giles
- Research Associate, Health Policy, Politics & Organisation (HiPPO), University of Manchester, UK
| | - Imelda McDermott
- Research Fellow, Health Policy, Politics & Organisation (HiPPO), University of Manchester, UK
| | - Kath Checkland
- Professor of Health Policy & Primary Care, Health Policy, Politics & Organisation (HiPPO), University of Manchester, UK
| | - Valerie Moran
- Postdoctoral Fellow, Department of Population Health, Luxembourg Institute of Health, Luxembourg.,Researcher, Living Conditions, Luxembourg Institute of Socio-Economic Research, Luxembourg
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Hammond J, Mason T, Sutton M, Hall A, Mays N, Coleman A, Allen P, Warwick-Giles L, Checkland K. Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening. BMJ Open 2019; 9:e024156. [PMID: 30987985 PMCID: PMC6500278 DOI: 10.1136/bmjopen-2018-024156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms. METHODS Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes. RESULTS Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups. CONCLUSIONS Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.
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Affiliation(s)
- Jonathan Hammond
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Mason
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alex Hall
- School of Health Sciences, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Nicholas Mays
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Abstract
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.
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Affiliation(s)
- Imelda McDermott
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Kath Checkland
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Valerie Moran
- Luxembourg Institute of Health and Luxembourg Institute of Socio-Economic Research, Luxembourg, Luxembourg
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Checkland K. Commentary on 'The art and science of non-evaluation evaluation'. J Health Serv Res Policy 2018; 23:268-269. [PMID: 30269596 DOI: 10.1177/1355819618790610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kath Checkland
- Professor of Health Policy and Primary Care Health Policy, Politics & Organisation (HiPPO) Research Group, Centre for Primary Care Division of Population Health, Health Services Research and Primary Care, University of Manchester, Oxford Road, Manchester M13 9PL, UK
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Warwick-Giles L, Coleman A, Checkland K. Co-owner, service provider, critical friend? The role of public health in clinical commissioning groups. J Public Health (Oxf) 2018; 38:633-634. [PMID: 28158833 DOI: 10.1093/pubmed/fdv137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Warwick-Giles
- Health Policy Politics and Organisation Group, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester M13 9PL, UK
| | - A Coleman
- Health Policy Politics and Organisation Group, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester M13 9PL, UK
| | - K Checkland
- Health Policy Politics and Organisation Group, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester M13 9PL, UK
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Hall A, Hammond J, Bramwell D, Coleman A, Warwick-Giles L, Checkland K. Beyond the parish pump: what next for public health? BMC Public Health 2018; 18:856. [PMID: 29996807 PMCID: PMC6042454 DOI: 10.1186/s12889-018-5791-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/04/2018] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Alex Hall
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Jonathan Hammond
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Donna Bramwell
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Elvey R, Bailey S, Checkland K, McBride A, Parkin S, Rothwell K, Hodgson D. Implementing new care models: learning from the Greater Manchester demonstrator pilot experience. BMC Fam Pract 2018; 19:89. [PMID: 29921230 PMCID: PMC6006551 DOI: 10.1186/s12875-018-0773-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 05/21/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Rebecca Elvey
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Simon Bailey
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Kath Checkland
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Anne McBride
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Stephen Parkin
- Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - Katy Rothwell
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Salford Royal Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Damian Hodgson
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Abstract
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.
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Hammond J, Coleman A, Checkland K. Enacting localist health policy in the English NHS: the 'governing assemblage' of Clinical Commissioning Groups. J Health Serv Res Policy 2017; 23:49-56. [PMID: 29256272 DOI: 10.1177/1355819617739039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Hammond
- 1 Research Fellow, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, The University of Manchester, UK
| | - Anna Coleman
- 2 Senior Research Fellow, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, The University of Manchester, UK
| | - Kath Checkland
- 3 Professor of Health Policy and Primary Care, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, The University of Manchester, UK
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Moran V, Allen P, McDermott I, Checkland K, Warwick-Giles L, Gore O, Bramwell D, Coleman A. How are clinical commissioning groups managing conflicts of interest under primary care co-commissioning in England? A qualitative analysis. BMJ Open 2017; 7:e018422. [PMID: 29122801 PMCID: PMC5695513 DOI: 10.1136/bmjopen-2017-018422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Valerie Moran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pauline Allen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Imelda McDermott
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Oz Gore
- Division of Population Health, Health Services Research and Primary Care and Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Donna Bramwell
- Division of Population Health, Health Services Research and Primary Care and Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
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Spooner S, Pearson E, Gibson J, Checkland K. How do workplaces, working practices and colleagues affect UK doctors' career decisions? A qualitative study of junior doctors' career decision making in the UK. BMJ Open 2017; 7:e018462. [PMID: 29074517 PMCID: PMC5665284 DOI: 10.1136/bmjopen-2017-018462] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Sharon Spooner
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Emma Pearson
- Department of Psychology, Edge Hill University, Ormskirk, Lancashire, UK
| | - Jonathan Gibson
- Division of Population Health, Health Services Research and Primary Care, Centre for Health Economics, University of Manchester, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
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Hammond J, Lorne C, Coleman A, Allen P, Mays N, Dam R, Mason T, Checkland K. The spatial politics of place and health policy: Exploring Sustainability and Transformation Plans in the English NHS. Soc Sci Med 2017; 190:217-226. [DOI: 10.1016/j.socscimed.2017.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/13/2017] [Accepted: 08/09/2017] [Indexed: 11/15/2022]
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Tammes P, Morris RW, Brangan E, Checkland K, England H, Huntley A, Lasserson D, MacKichan F, Salisbury C, Wye L, Purdy S. 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. BMC Health Serv Res 2017; 17:546. [PMID: 28789652 PMCID: PMC5549356 DOI: 10.1186/s12913-017-2483-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Richard W Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emer Brangan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona MacKichan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Stokes J, Kristensen SR, Checkland K, Cheraghi-Sohi S, Bower P. Does the impact of case management vary in different subgroups of multimorbidity? Secondary analysis of a quasi-experiment. BMC Health Serv Res 2017; 17:521. [PMID: 28774296 PMCID: PMC5543754 DOI: 10.1186/s12913-017-2475-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/26/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK. .,Manchester Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Søren Rud Kristensen
- Manchester Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Checkland
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Abstract
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.
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Affiliation(s)
- Valerie Moran
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Sharon Spooner
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Jonathan Gibson
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Matt Sutton
- Centre for Health Economics, University of Manchester, Manchester, UK
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MacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, Morris R, Tammes P, Salisbury C, Purdy S. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open 2017; 7:e013816. [PMID: 28473509 PMCID: PMC5623418 DOI: 10.1136/bmjopen-2016-013816] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Fiona MacKichan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emer Brangan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lesley Wye
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alyson Huntley
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard Morris
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter Tammes
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Bailey S, Checkland K, Hodgson D, McBride A, Elvey R, Parkin S, Rothwell K, Pierides D. The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS. Soc Sci Med 2017; 179:210-217. [PMID: 28284538 DOI: 10.1016/j.socscimed.2017.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/15/2016] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- S Spooner
- Division of Population Health, The University of Manchester, Health Services Research & Primary Care, Manchester, UK
| | - Jon Gibson
- Division of Population Health, The University of Manchester, Health Services Research & Primary Care, Manchester, UK
| | - Dan Rigby
- Economics, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, The University of Manchester, Health Services Research & Primary Care, Manchester, UK
| | - Emma Pearson
- Division of Population Health, The University of Manchester, Health Services Research & Primary Care, Manchester, UK
| | - Kath Checkland
- Division of Population Health, The University of Manchester, Health Services Research & Primary Care, Manchester, UK
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Abstract
'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.
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Affiliation(s)
- Jonathan Stokes
- Research Associate, NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Kath Checkland
- Professor, Centre for Primary Care, NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Søren Rud Kristensen
- Research Fellow, Manchester Centre for Health Economics, University of Manchester, UK
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McDermott I, Checkland K, Coleman A, Osipovič D, Petsoulas C, Perkins N. Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS. J Health Serv Res Policy 2016; 22:4-11. [PMID: 27151153 PMCID: PMC5207294 DOI: 10.1177/1355819616648352] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Imelda McDermott
- 1 Research Fellow, Centre for Primary Care, University of Manchester, UK
| | - Kath Checkland
- 2 Professor of Health Policy & Primary Care, Centre for Primary Care, University of Manchester, UK
| | - Anna Coleman
- 1 Research Fellow, Centre for Primary Care, University of Manchester, UK
| | - Dorota Osipovič
- 3 Research Fellow, London School of Hygiene and Tropical Medicine, UK
| | | | - Neil Perkins
- 4 Research Associate, Centre for Primary Care, University of Manchester, UK
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Tammes P, Morris RW, Brangan E, Checkland K, England H, Huntley A, Lasserson D, MacKichan F, Salisbury C, Wye L, Purdy S. 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. Emerg Med J 2016; 33:702-8. [PMID: 27317586 DOI: 10.1136/emermed-2015-205339] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 05/14/2016] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard W Morris
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emer Brangan
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Alyson Huntley
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fiona MacKichan
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Abstract
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.
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Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Søren Rud Kristensen
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Kath Checkland
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A, Boaden R, Braithwaite J, Britten N, Carnevale F, Checkland K, Cheek J, Clark A, Cohn S, Coulehan J, Crabtree B, Cummins S, Davidoff F, Davies H, Dingwall R, Dixon-Woods M, Elwyn G, Engebretsen E, Ferlie E, Fulop N, Gabbay J, Gagnon MP, Galasinski D, Garside R, Gilson L, Griffiths P, Hawe P, Helderman JK, Hodges B, Hunter D, Kearney M, Kitzinger C, Kitzinger J, Kuper A, Kushner S, Le May A, Legare F, Lingard L, Locock L, Maben J, Macdonald ME, Mair F, Mannion R, Marshall M, May C, Mays N, McKee L, Miraldo M, Morgan D, Morse J, Nettleton S, Oliver S, Pearce W, Pluye P, Pope C, Robert G, Roberts C, Rodella S, Rycroft-Malone J, Sandelowski M, Shekelle P, Stevenson F, Straus S, Swinglehurst D, Thorne S, Tomson G, Westert G, Wilkinson S, Williams B, Young T, Ziebland S. An open letter to The BMJ editors on qualitative research. BMJ 2016; 352:i563. [PMID: 26865572 DOI: 10.1136/bmj.i563] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
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.
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Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0132340. [PMID: 26186598 PMCID: PMC4505905 DOI: 10.1371/journal.pone.0132340] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/14/2015] [Indexed: 11/19/2022] Open
Abstract
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).
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Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Rahul Alam
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Kath Checkland
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Miller R, Peckham S, Coleman A, McDermott I, Harrison S, Checkland K. What happens when GPs engage in commissioning? Two decades of experience in the English NHS. J Health Serv Res Policy 2015; 21:126-33. [PMID: 26158276 DOI: 10.1177/1355819615594825] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Rosalind Miller
- PhD Student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Stephen Peckham
- Professor of Health Policy, Centre for Health Services Studies, University of Kent, UK
| | - Anna Coleman
- Research Fellow, Centre for Primary Care, University of Manchester, UK
| | - Imelda McDermott
- Research Associate, Centre for Primary Care, University of Manchester, UK
| | - Stephen Harrison
- Professor of Social Policy, Centre for Primary Care, University of Manchester, UK
| | - Kath Checkland
- Reader in Health Policy and Primary Care, Centre for Primary Care, University of Manchester, UK
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