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1.  The work of commissioning: a multisite case study of healthcare commissioning in England's NHS 
BMJ Open  2013;3(9):e003341.
Objective
To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.
Design
Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.
Participants
Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.
Setting
Three ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.
Results
Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.
Conclusions
Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
doi:10.1136/bmjopen-2013-003341
PMCID: PMC3773628  PMID: 24014483
Health Services Administration & Management; Qualitative Research
2.  Commissioning healthcare for people with long term conditions: the persistence of relational contracting in England’s NHS quasi-market 
BMC Health Services Research  2013;13(Suppl 1):S2.
Background
Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.
Methods
We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.
Results
In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.
In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.
Conclusions
Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.
doi:10.1186/1472-6963-13-S1-S2
PMCID: PMC3663656  PMID: 23735008
3.  Studying policy implementation using a macro, meso and micro frame analysis: the case of the Collaboration for Leadership in Applied Health Research & Care (CLAHRC) programme nationally and in North West London 
Background
The publication of Best research for best health in 2006 and the “ring-fencing” of health research funding in England marked the start of a period of change for health research governance and the structure of research funding in England. One response to bridging the ‘second translational gap’ between research knowledge and clinical practice was the establishment of nine Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). The goal of this paper is to assess how national-level understanding of the aims and objectives of the CLAHRCs translated into local implementation and practice in North West London.
Methods
This study uses a variation of Goffman’s frame analysis to trace the development of the initial national CLAHRC policy to its implementation at three levels. Data collection and analysis were qualitative through interviews, document analysis and embedded research.
Results
Analysis at the macro (national policy), meso (national programme) and micro (North West London) levels shows a significant common understanding of the aims and objectives of the policy and programme. Local level implementation in North West London was also consistent with these.
Conclusions
The macro-meso-micro frame analysis is a useful way of studying the transition of a policy from high-level idea to programme in action. It could be used to identify differences at a local (micro) level in the implementation of multi-site programmes that would help understand differences in programme effectiveness.
doi:10.1186/1478-4505-10-32
PMCID: PMC3503608  PMID: 23067208
Policy implementation; Policy analysis; Frame analysis; Knowledge translation; Health services research; Translational gap
4.  Implementing practice based commissioning 
BMJ : British Medical Journal  2007;335(7631):1168.
Is happening slowly but not necessarily surely
doi:10.1136/bmj.39414.429838.BE
PMCID: PMC2128645  PMID: 18063613
5.  Who needs what from a national health research system: lessons from reforms to the English Department of Health's R&D system 
Health research systems consist of diverse groups who have some role in health research, but the boundaries around such a system are not clear-cut. To explore what various stakeholders need we reviewed the literature including that on the history of English health R&D reforms, and we also applied some relevant conceptual frameworks.
We first describe the needs and capabilities of the main groups of stakeholders in health research systems, and explain key features of policymaking systems within which these stakeholders operate in the UK. The five groups are policymakers (and health care managers), health professionals, patients and the general public, industry, and researchers. As individuals and as organisations they have a range of needs from the health research system, but should also develop specific capabilities in order to contribute effectively to the system and benefit from it.
Second, we discuss key phases of reform in the development of the English health research system over four decades - especially that of the English Department of Health's R&D system - and identify how far legitimate demands of key stakeholder interests were addressed.
Third, in drawing lessons we highlight points emerging from contemporary reports, but also attempt to identify issues through application of relevant conceptual frameworks. The main lessons are: the importance of comprehensively addressing the diverse needs of various interacting institutions and stakeholders; the desirability of developing facilitating mechanisms at interfaces between the health research system and its various stakeholders; and the importance of additional money in being able to expand the scope of the health research system whilst maintaining support for basic science.
We conclude that the latest health R&D strategy in England builds on recent progress and tackles acknowledged weaknesses. The strategy goes a considerable way to identifying and more effectively meeting the needs of key groups such as medical academics, patients and industry, and has been remarkably successful in increasing the funding for health research. There are still areas that might benefit from further recognition and resourcing, but the lessons identified, and progress made by the reforms are relevant for the design and coordination of national health research systems beyond England.
doi:10.1186/1478-4505-8-11
PMCID: PMC2881918  PMID: 20465789
6.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
Background
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Results
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
Conclusion
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
doi:10.1186/1743-8462-5-24
PMCID: PMC2588611  PMID: 18990236
7.  Informing Policy Making and Management in Healthcare: The Place for Synthesis 
Healthcare Policy  2006;1(2):43-48.
Research synthesis has an important role supporting the transfer of knowledge between researchers and healthcare decision-makers. But if our goal is to make knowledge more useable and context specific, then extending the scope of systematic reviews or producing syntheses with policy makers and managers may be insufficient. Dialogues, partnerships and reinterpretations of evidence in context will help us achieve this goal.
PMCID: PMC2585321  PMID: 19305652
8.  Are New Zealand's new primary health organisations fit for purpose? 
BMJ : British Medical Journal  2006;333(7580):1216-1218.
Attempts to make New Zealand's health care more equitable have resulted in rapid change. But the reforms are largely untested and their effects difficult to predict
doi:10.1136/bmj.39029.493542.94
PMCID: PMC1693623  PMID: 17158390
9.  Describing the impact of health research: a Research Impact Framework 
Background
Researchers are increasingly required to describe the impact of their work, e.g. in grant proposals, project reports, press releases and research assessment exercises. Specialised impact assessment studies can be difficult to replicate and may require resources and skills not available to individual researchers. Researchers are often hard-pressed to identify and describe research impacts and ad hoc accounts do not facilitate comparison across time or projects.
Methods
The Research Impact Framework was developed by identifying potential areas of health research impact from the research impact assessment literature and based on research assessment criteria, for example, as set out by the UK Research Assessment Exercise panels. A prototype of the framework was used to guide an analysis of the impact of selected research projects at the London School of Hygiene and Tropical Medicine. Additional areas of impact were identified in the process and researchers also provided feedback on which descriptive categories they thought were useful and valid vis-à-vis the nature and impact of their work.
Results
We identified four broad areas of impact:
I. Research-related impacts;
II. Policy impacts;
III. Service impacts: health and intersectoral and
IV. Societal impacts.
Within each of these areas, further descriptive categories were identified. For example, the nature of research impact on policy can be described using the following categorisation, put forward by Weiss:
Instrumental use where research findings drive policy-making;
Mobilisation of support where research provides support for policy proposals;
Conceptual use where research influences the concepts and language of policy deliberations and
Redefining/wider influence where research leads to rethinking and changing established practices and beliefs.
Conclusion
Researchers, while initially sceptical, found that the Research Impact Framework provided prompts and descriptive categories that helped them systematically identify a range of specific and verifiable impacts related to their work (compared to ad hoc approaches they had previously used). The framework could also help researchers think through implementation strategies and identify unintended or harmful effects. The standardised structure of the framework facilitates comparison of research impacts across projects and time, which is useful from analytical, management and assessment perspectives.
doi:10.1186/1472-6963-6-134
PMCID: PMC1635046  PMID: 17049092
10.  Practice based commissioning: applying the research evidence 
BMJ : British Medical Journal  2005;331(7529):1397-1399.
General practitioners are being asked to retake responsibility for commissioning healthcare services. What can we learn from previous experience?
PMCID: PMC1309657  PMID: 16339254
11.  Primary care trusts: do they have a future? 
BMJ : British Medical Journal  2005;331(7526):1156-1157.
PMCID: PMC1285082  PMID: 16293814
15.  Analysing qualitative data 
BMJ : British Medical Journal  2000;320(7227):114-116.
PMCID: PMC1117368  PMID: 10625273
16.  Assessing quality in qualitative research 
BMJ : British Medical Journal  2000;320(7226):50-52.
PMCID: PMC1117321  PMID: 10617534
18.  Evaluation of total purchasing pilots in England and Scotland and implications for primary care groups in England: personal interviews and analysis of routine data 
BMJ : British Medical Journal  1998;317(7153):256-259.
Objectives: To evaluate the reported achievements of the 52 first wave total purchasing pilot schemes in 1996-7 and the factors associated with these; and to consider the implications of these findings for the development of the proposed primary care groups.
Design: Face to face interviews with lead general practitioners, project managers, and health authority representatives responsible for each pilot; and analysis of hospital episode statistics.
Setting: England and Scotland for evaluation of pilots; England only for consideration of implications for primary care groups.
Main outcome measures: The ability of total purchasers to achieve their own objectives and their ability specifically to achieve objectives in the service areas beyond fundholding included in total purchasing.
Results: The level of achievement between pilots varied widely. Achievement was more likely to be reported in primary than in secondary care. Reported achievements in reducing length of stay and emergency admissions were corroborated by analysis of hospital episode statistics. Single practice and small multipractice pilots were more likely than large multipractice projects to report achieving their objectives. Achievements were also associated with higher direct management costs per head and the ability to undertake independent contracting. Large multipractice pilots required considerable organisational development before progress could be made.
Conclusion: The ability to create effective commissioning organisations the size of the proposed primary care groups should not be underestimated. To be effective commissioners, these care groups will need to invest heavily in their organisational development and in the short term are likely to need an additional development budget rather than the reduction in spending on NHS management that is planned by the government.
Key messages The level of reported achievement between the total purchasing pilots in 1996-7 varied widely; achievement was more likely to occur in primary than in secondary care Single practice and small multipractice pilots were more likely than large multipractice pilots to report achieving their objectives in 1996/97; achievements were also associated with higher direct management costs per head Large multipractice pilots needed more time for organisational development before progress could be made Difficulties in creating effective commissioning organisations the size of the proposed primary care groups should not be underestimated Primary care groups will need to invest heavily in organisational development and are likely to need an additional development budget in the short term
PMCID: PMC28618  PMID: 9677217
21.  New public health 
BMJ : British Medical Journal  1994;308(6943):1569.
PMCID: PMC2540506
23.  Moulded of things past 
BMJ : British Medical Journal  1990;301(6758):1000.
Images
PMCID: PMC1664174

Results 1-25 (25)