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As discussed in Chapters 1 and 2, one of the central tenets of the HSCA 2012 was the desirability of increasing the involvement of GPs (and other clinicians) in the commissioning of services for their patients. This ideological commitment – based upon belief and founded, in part at least, upon an implicit denigration of managerial work (in order to increase control over the NHS and commissioners), had far-reaching consequences in the design of the reforms. For example, the initial separation of responsibility for commissioning primary care services from secondary and community services was deemed necessary because of the potential for conflicts of interest, whilst the creation of CCGs as ‘membership organisations’ had, as seen in Chapter 3, significant implications for their organisation and governance. The initial White Paper, ‘Equity and Excellence’ (Department of Health, 2010a: 9) was relatively non-specific about the expected benefits of clinical leadership of commissioning. It was argued that:
The headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic. The Government will liberate the NHS from excessive bureaucratic and political control, and make it easier for professionals to do the right things for and with patients, to innovate and improve outcomes.
The document suggested that the proposals would: ‘liberate professionals and providers from top down control’; shift decision making closer to patients; enable better dialogue between primary and secondary care practitioners; and ensure that service development had real clinical involvement. However, the mechanisms underlying these perceived benefits were unstated. Furthermore, it was claimed that, whilst previous incarnations of GP-led commissioning (which in the UK go back to the creation of ‘GP fundholding’ in the 1990s) had delivered some benefits, these had been limited by the failure to give those involved complete autonomy and real budgets. The creation of CCGs, it was argued, would remedy these problems and ‘liberate’ clinicians to significantly improve care.
The wide-ranging reforms made to health and care systems in England, as part of the HSCA 2012, created an enormous shakeup of the way the public health function is delivered. Key public health responsibilities were transferred from the NHS to local government councils. In addition, PHE was established as the national agency for public health.
This chapter examines what these changes have meant for the commissioning of services to improve population health. Commissioning in relation to the health improvement function refers to the strategic planning and purchasing of services that could include smoking cessation, weight management and drug and alcohol services, public health services for children and young people, comprehensive sexual health services and campaigns, dental public health services and services to prevent cancer and long-term conditions.
The political backdrop
The government's goal was to develop a ‘public health service that achieves excellent results, unleashing innovation and liberating professional leadership’ (Department of Health, 2010b). There were a number of important themes demonstrated in the structural changes. First, they represented an attempt to enhance democratic accountability and challenge the old ‘command and control’ model. Within the wider context of the localism agenda, the relocation of public health functions was an attempt to ensure that local people made local decisions to improve the health of local populations. Second, the government was attempting to shift the focus from processes onto outcomes. A comprehensive set of indicators were developed within a ‘public health outcomes framework’, against which local public health systems would be assessed. This would enable transparency and an element of comparability between different local areas. Third, there was an attempt to take a ‘different’ (though not new) approach to public health – one that takes a ‘life course’ perspective, and that places importance on wider determinants of health, particularly in relation to people's socioeconomic contexts. Fourth, there was a focus on ensuring that decisions are based on the best possible evidence of what works – a key role for PHE. Fifth, there was an emphasis on efficiency, particularly with regard to being ‘joined up’ and streamlined. And finally, consistent with wider policy, there was a general push towards commissioning, and lead organisations being solely commissioning organisations.
The optimal balance between central governmental authority and the degree of autonomy of local public bodies is an enduring issue in public policy. The UK National Health Service is no exception, with NHS history, in part at least, a history of repeated cycles of centralisation and decentralisation of decision-making power. Most recently, a significant reorganisation of the NHS in 2012–13 was built around the creation of new and supposedly more autonomous commissioning organisations (Clinical Commissioning Groups – CCGs). Using Bossert's (1998) concept of ‘decision space’, we explored the experiences of local commissioners as they took on their new responsibilities. We interviewed commissioning staff from all of the CCGs in two regional health care ‘economies’, exploring their perceptions of autonomy and their experiences over time. We found significant early enthusiasm for, and perceptions of, increased autonomy tempered in the vertical dimension by increasingly onerous and prescriptive monitoring regimes, and in the horizontal dimension by the proliferation of overlapping networks, inter-organisational groups and relationships. We propose that, whatever the balance between central and local control that is adopted, complex public services require some sort of meso-level oversight from organisations able to ‘hold the ring’ between competing interests and to take a regional view of the needs of the local health system. This suggests that local organisational autonomy in such services will always be constrained.
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