How managed a market? Modes of commissioning in England and Germany

Sheaff, Rod; Chambers, Naomi; Charles, Nigel; Exworthy, Mark; Mahon, Ann; Byng, Richard; Mannion, Russell

doi:10.1186/1472-6963-13-s1-s8

Cited by 16 publications

(19 citation statements)

References 12 publications

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“…For example, supplier opportunism in the context of Private Finance Initiative contracting in the NHS leads public-sector managers to employ detailed planning practices (Lonsdale and Watson, 2007) and hold private-sector managers accountable to contract specifications (Hebson, Grimshaw and Marchington, 2003), potentially leading to a more difficult situation for profit-making. Moreover, commissioning in English healthcare has traditionally limited competition, since patient choice and cash budgets were both strictly limited (Sheaff et al, 2013).…”

Section: The Conditions Of Profitabilitymentioning

confidence: 99%

When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act

Krachler

Greer

2015

Social Science & Medicine

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Governments world-wide have attempted to use market mechanisms and privatisation to increase the quality and/or reduce the cost of healthcare. England's Health and Social Care Act 2012 is an attempt to promote privatisation through marketisation in the National Health Service (NHS). While the health policy literature tends to assume that privatisation follows from private-sector entry points, we argue that this is more likely if firms expect to make a profit. This paper examines the link between privatisation and marketisation in England drawing on 32 semi-structured interviews with private-sector and public-sector respondents, campaigners, and other experts conducted 6-10 months after the implementation of the 2012 Act.By generating a theoretical framework on the conditions of profitability we seek a better understanding of the conditions under which marketisation leads to privatisation. We find that significant barriers to profit-making remain after the reforms, including a top-down squeeze on prices, uncertainty in market rules, state dominance of funding and provision, and failures to depoliticise the market. These factors restrict privatesector involvement by frustrating profit-making. Where profits are made they are through reduced unit costs and high volumes by a longstanding incumbent in a particular market segment. This, however, restricts marketisation by reinforcing entry barriers Governments world-wide have attempted to use market mechanisms and privatisation to increase the quality and/or reduce the cost of healthcare. 1 England's Health and Social Care Act 2012 is an attempt to promote privatisation through marketisation in the National Health Service (NHS). While the health policy literature tends to assume that privatisation follows from private-sector entry points, we argue that this is more likely if firms expect to make a profit. This paper examines the link between privatisation and marketisation in England drawing on 32 semi-structured interviews with private-sector and public-sector respondents, campaigners, and other experts conducted 6-10 months after the implementation of the 2012 Act. Suggested Citation Krachler, N., & Greer, I. (2015). When does marketisation lead to privatisation? Profit-making in English healthBy generating a theoretical framework on the conditions of profitability we seek a better understanding of the conditions under which marketisation leads to privatisation. We find that significant barriers to profit-making remain after the reforms, including a top-down squeeze on prices, uncertainty in market rules, state dominance of funding and provision, and failures to depoliticise the market. These factors restrict private-sector involvement by frustrating profit-making. Where profits are made they are through reduced unit costs and high volumes by a longstanding incumbent in a particular market segment. This, however, restricts marketisation by reinforcing entry barriers.

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Section: The Conditions Of Profitabilitymentioning

confidence: 99%

When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act

Krachler

Greer

2015

Social Science & Medicine

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“…With respect to service use, Barnes et al (2013) found that in the context of inappropriate treatment of routine childhood (Baxter et al 2007; PCT case study); characteristics of commissioning managers (Checkland et al 2012; PCT); perceptions of value of priority-setting tools (decision support) for resource allocation (Marks et al 2011;PCTs); commissioning services for long-term conditions (Shaw et al 2013;PCTs); priority setting and rationing in PCTs (Robinson et al 2012; PCT case study); AFR framework to aid decision making (Bravo Vergel and Ferguson 2006;PCT); comparisons across commissioning models in Germany and UK (Sheaff et al 2013; PCT and other); views of CCG versus PCT commissioning (Turner et al 2013;PCT and CCG); are GPs best placed to deliver equity and excellence? Comparing GP commissioning with PCT (Gridley et al 2012; PCT and other); APMS contractual processes ; UK APMS); commissioning dental services through PDSS (Newton et al 2006; PDSS); barriers and enablers to commissioning ; PCT survey); engaging pharmacy in pharmaceutical needs assessment for commissioning pharmacy ; PCT) Quantitative: cluster RCT examining impact of commissioning on smoking cessation and entrance of new market players (McLeod et al 2015;PCTs); PBMA for purchasing (Wilson et al 2007; PCT) Mixed methods: redesigning children's services (Barnes et al 2013; PCT); use of external consultants by NHS commissioners (Naylor and Goodwin 2011; PCT interviews and survey); commissioners viewed HLP scheme as an effective model with which to deliver increased volume, quality and reliability of community health services (Kennington et al 2013; HLP) Fundholding practices (n = 1); PBC (n = 2); CCGs (n = 7) 1 quantitative; 9 qualitative 10 Quantitative: impact on cost containment and service use (Dusheiko et al 2006; fundholding) Qualitative: barriers to PBC (Checkland et al 2009; PBC); PBC as a service redesign tool (Slater and White 2007;PBC); investigating disinvestment practices (Rooshenas et al 2013;CCG); exploring development of CCG CCG); attitudes of GPs to commissioning including level of GP engagement with clinical commissioning and attitudes to incentives an...…”

Section: Evidence Of Impact Of Commissioningmentioning

confidence: 99%

A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy

Gardner

Davies

Edwards

et al. 2016

Aust. J. Prim. Health

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Abstract. The aim of this systematic review was to assess evidence of the impact of commissioning on health service use, quality, outcomes and value for money and to consider findings in the Australian context. Systematic searches of the literature identified 444 papers and, after exclusions, 36 were subject to full review. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis and impacts were assessed at individual, subpopulation and population levels. Little evidence of the effectiveness of commissioning at any level was available and observed impacts were highly context-dependent. There was insufficient evidence to identify a preferred model. Lack of skills and capacity were cited as major barriers to the implementation of commissioning. Successful commissioning requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Engagement of consumers and providers, especially physicians, was considered to be critically important but is time consuming and has proven difficult to sustain. Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, and for contracting and monitoring performance. Lack of information resulted in serious problems. High-quality nationally standardised performance measures and data requirements need to be built into contracts and ongoing monitoring and evaluation. In Australia, there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning.

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“…Most important, regulations intended to maximise provider diversity and competition for patients removed provider competition as a medium of commissioner power. 267 …”

Section: Juridical Controlsmentioning

confidence: 99%

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Sheaff

Charles

Mahon

et al. 2015

Health Services and Delivery Research

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BackgroundBy 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).ObjectivesTo: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.DesignMixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.ResultsIn the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.ConclusionsCommissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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How managed a market? Modes of commissioning in England and Germany

Cited by 16 publications

References 12 publications

When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act

When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act

A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

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