The practice of commissioning healthcare from a private provider: learning from an in-depth case study

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

doi:10.1186/1472-6963-13-s1-s4

Cited by 17 publications

(24 citation statements)

References 25 publications

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“…We found factors contributing to success included building effective working relationships, which were partial in vignette 1 and absent in vignettes 2 (hospital audit) and 4 (data-driven commissioning). The importance of trust and good working relationships was also identified in a post-2012, single case study of collaboration between clinical commissioners and external providers17 and in a recent study of commissioning support units 29. In fact, this latter study concluded that good quality internal relationships are so important to commissioners, that in commissioners’ determination to forge these links, they are bringing commissioning support analysts, who were their former commissioning colleagues before the 2012 Health and Social Care Act, back into CCGs.…”

Section: Discussionmentioning

confidence: 99%

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange

et al. 2015

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ObjectivesThe use of external consultants from private and not-for-profit providers in the National Health Service (NHS) is intended to improve the quality of commissioning. The aim of this study was to learn about the support offered to healthcare commissioners, how external consultants and their clients work together and the perceived impact on the quality of commissioning.SettingNHS commissioning organisations and private and not-for-profit providers.DesignMixed methods case study of eight cases.Data collection92 interviews with external consultants (n=36), their clients (n=47) and others (n=9). Observation of 25 training events and meetings. Documentation, for example, meeting minutes and reports.AnalysisConstant comparison. Data were coded, summarised and analysed by the research team with a coding framework to facilitate cross-case comparison.ResultsIn the four contracts presented here, external providers offered technical solutions (eg, software tools), outsourcing and expertise including project management, data interpretation and brokering relationships with experts. In assessing perceived impact on quality of commissioning, two contracts had limited value, one had short-term benefits and one provided short and longer term benefits. Contracts with commissioners actively learning, embedding and applying new skills were more valued. Other elements of success were: (1) addressing clearly agreed problems of relevance to managerial and operational staff (2) solutions co-produced at all organisational levels (3) external consultants working directly with clients to interpret data outputs to inform locally contextualised commissioning strategies. Without explicit knowledge exchange strategies, outsourcing commissioning to external providers resulted in the NHS clients becoming dependent.ConclusionsNHS commissioning will be disadvantaged if commissioners both fail to learn in the short term from the knowledge of external providers and in the longer term lose local skills. Knowledge exchange mechanisms are a vital component of commissioning and should be embedded in external provider contracts.

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Section: Discussionmentioning

confidence: 99%

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange

et al. 2015

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“…157 Corporations and public bureaucracies 154 can exploit the formalisation and standardisation of work processes to routinise, automate and deskill work, using cheaper, more flexible staffing arrangements, and to that extent increase labour productivity. Examples of this tendency include the introduction of call centres, [158][159][160] telephone-based care management 160 and the development of case-load norms for community matrons. 36 A larger organisation (e.g.…”

Section: Care Plansmentioning

confidence: 99%

Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

Sheaff

Halliday

Øvretveit

et al. 2015

Health Serv Deliv Res

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BackgroundAn ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.ObjectivesTo examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.MethodsMultiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.ResultsStarting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.ConclusionsOn balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Livewell bought substantial support from a US HMO to develop a unified view, across the commissioners, GPs and other primary care providers, about what services should be commissioned, monitored and reviewed. 238 Overload was less evident in Milltown, perhaps because so many GPs contributed to commissioning there. It became more severe the year before CCGs went live, with less work being done on commissioning initiatives, revising service specifications (Metroland) and setting public health priorities (Porttown).…”

Section: Overloadmentioning

confidence: 99%

“…In Livewell that someone else was a US HMO, engaged by the PCT (under pressure from general practices), which with those general practices comprehensively redesigned services for this care group, building in risk assessment and telephone support services. 238 Learning set members, however, emphasised that these integrative activities were not as routine as they ought to be, because of such impasses as the hospital asking the PCT to identify which patients to divert to community care, and to which services, but the PCT being unable to do so. Metroland PCT did not set targets for hospital discharge or providing services to prevent readmissions.…”

Section: Recurrent Unplanned Admissionsmentioning

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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The practice of commissioning healthcare from a private provider: learning from an in-depth case study

Cited by 17 publications

References 25 publications

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange

Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

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

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