Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

Abstract

BackgroundThe wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.MethodsWe conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.ResultsPublic health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.ConclusionsOur findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Factors in implementation of clinical commissioning policy in improving health and wellbeing and/or reducing health inequalities in the English NHS: a systematic review of the evidence

“…We identi ed 2166 references, scanned 133 titles and abstracts and retrieved 42 publications for full texts. From these, we included six studies (including a total of 1155 participants) that reported data on clinical commissioning and health inequalities [46][47][48][49][50][51] and excluded 36 studies (Additional le 2). Of the six, four were qualitative.…”

“…Commissioning was considered as one of the broad aspects of public health activity […] identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance. 51 Responsibility for the health inequalities agenda was seen primarily as a function of public health roles rather than part and parcel of core healthcare commissioning work, even where PCTs had adopted explicit strategic priorities relating to inequalities. 47 CCGs understand primary care and local needs.…”

“…And we saw public health staff working hard to in uence the wider workforce. 51 Both local authorities had a long-term strategic commitment to community development and asset-based approaches, which was seen as bene cial by public health commissioners. 48 c) Partnership and engagement: The association between CC and wider healthcare partnership and engagement has been reported positively in terms of meeting healthcare needs by reducing duplication costs/resources and sharing knowledge and expertise.…”

“…Similarly, studies reported commissioning responsibilities have been fragmented between different organisations (NHS England, PHE, local councils and CCGs), and co-ordination was slow, di cult and bureaucratic. 48,51 Therefore, there was serious concern raised not only about diluting local authorities' action on health inequalities but also failing to recognise and reduce health inequalities because of poor direction from central government and poor commissioner engagement in health services commissioning. 47,49 The extracts below illustrate this:…”

“…However, with commissioning responsibilities now fragmented between NHS England, PHE, local councils and CCGs, our research found that co-ordination was proving to be di cult. 51 Local councils received their public health staff, resources and duties at a time of unprecedented cuts to their budgets. 16 These cuts precipitated ongoing restructures within councils to streamline their organisations and reduce sta ng costs.…”