health and social care act 2012 essay

Essay on Health and Social Care Act of 2012

Government policy formulation is always triggered by some aspects, which are aimed to improve service delivery to users within an economy. Provision of healthcare facilities is sensitive, and practitioners in the field should exhibit a high level of professionalism for the achievement of sustainability in the sector (Adams, 2007). For instance, social issues within a population can prompt the government to formulate strategies to handle the problem. Circumstances such as disease outbreak within a population can influence the formulation of specific policies as it relates to healthcare (Williams, 2002). The study focuses on evaluating an existing government policy and its relevance to service users. Equally, the paper will seek to gain an understanding of the services that are provided by specific legislation or policy. A thorough discussion of the policy is important to provide insight into the phenomenon. The research will also seek to discuss the decision making process of the policy and possible impacts that are associated (Field and Brown, 2019). To meet the objectives set, the study will use the Health and Social Care Act of 2012 in the United Kingdom to explore the concept (Care Quality Commission, 2012). In essence, the report aims to discuss the Health and Social act of 2012 in its bid to establish facts that revolve around policy formulation.

The legislation was adopted as a way of driving the economy to sustainability by providing healthcare facilities. The need for sustainability in the field of healthcare necessitated the formulation of a framework that addresses issues that arise. The main aim is to improve the population health of a particular nation (Williams, 2002). The implementation of the framework saw the development of the National Health Service commissioning board and other groups with similar capabilities. For instance, the act stipulates the role of practitioners in various facilities in facilitating equity. There is a need to show equality in the provision of services to patients within a country. Upon its inception, the act was meant to instil excellence in the healthcare sector through the National Health Service (Field and Brown, 2019). The act stipulates what is required of each stakeholder in the provision o healthcare facilities in the United Kingdom. In essence, the act was established to ensure sustainability through the National Health Service (Walshe, 2012). The act was established to reduce the high level of inequality that was notable in the provision of services. For instance, minority groups are at a high risk of receiving poor services in the country. Both equality and excellence were required in the sector, which prompted many parliamentarians to rally behind the implementation of the act.

The Health and social care Act of 2012 was established to support equity in the healthcare sector, and at the same time, spearhead improved performance. The act mentions the responsibilities of various stakeholders in the industry. The first part concentrates on what the Secretary of State on health is obliged to do to promote sustainability (Williams, 2002). According to the act, the secretary of state should be held accountable on matters relating to the provision of standardized healthcare. Part one of the act saw the creation of the National Health Service commissioning board and the abolition of strategic health operations. The second phase of the act dealt with some provisions, including the abolition of the Health Protection Agency (HPA). Equally, functions of the HPA were transferred to the secretary of state for health. Biological substances and radiation protection was a provision introduced in the second part. The repealing of the AIDS control Act of 1987 was done in part two, including the duties that all bodies providing healthcare facilities are obliged to follow. The act underwent many transformations with subsequent parts covering important aspects in healthcare such as adult and child care facilities.

The impact of the implementation of the Health and Social Care Act of 2012 can be felt within the healthcare system of the country. For instance, the fact that the act supports equality in the provision of services has reduced disparities that were notable initially. Racial prejudice is still notable in the provision of healthcare facilities, even though the law discourages the same. The act asserts that all people are equal and should be treated fairly when receiving services, despite one’s skill color, culture and other factors (Sadek and Sadek, 2004). Equally, the legislation has been at the forefront of championing excellence within healthcare facilities. As such, the quality of service provision has improved over time, indicating how important it has been in shaping reforms within the healthcare sector. Every practitioner’s role is well outlined in the policy to enhance professionalism and improved service provision. Such provisions make healthcare employees committed to achieving high service delivery to people (Adams, 2007). The act is instrumental in controlling and offering guidance in a case where there is a conflict of interest, especially among clinical practitioners. Such conflicts affect one’s performance leading to poor service delivery in the healthcare sector. In essence, the health and social care act of 2012 is a legal framework that serves to ensure sustainability in Medicare provision.

Some policies were formulated as a way of controlling the behavior of workers in the Medicare industry. For instance, the act states what is required of the secretary of state to health as far as the provision of standardized healthcare facilities is concerned (Howieson, 2012). Such regulations are important at places of work with a view of promoting population health. Equally, the act included provisions to abolish the Health Protection Agency, which was replaced by a National Health Service board. The board has been efficient in ensuring that people in the country receive standardized Medicare services in an equal manner. In the Health and Social Care act, policies on child care and adult care devilment are handled (Field and Brown, 2019). The act served as a way of addressing significant issues in the health care sector that has derailed the achievement of a desirable level of population health. Policies that govern the distribution of resources for the provision of services are inclusive in the health and social care act of 2012. The policies have proved helpful in promoting equality, excellence and coverage of the healthcare facilities.

The Health and Social Care Act of 2012 has affected many people in the United Kingdom as service users in the Medicare field. For instance, service users have the privilege of receiving equal treatment as far as healthcare is concerned (Sadek and Sadek, 2004). Prejudice against a population that needs medicine is detrimental to improved universal healthcare. The government understands the importance of a healthy population and therefore, the need to excel in service provision. The health and social care act of 2012 rejuvenated society’s trust in the government to improve the delivery of healthcare services. With a list of guidelines and tasks of what one should perform at work, users experience convenience and efficient. In essence, users are benefitting from the strategies that were put in place through the act (Glover-Thomas, 2013). The act provides an opportunity for controlled drug pricing, which has promoted consumer welfare. Lack of such policing within the community exposes individuals to exploitation by unscrupulous business people. Equally, users are advantaged by the fact that there are better and improved hospital facilities.

Commission groups established within the society help detect any possible dangers that might risk the wellness of a population. In the event, the government can formulate plans to ensure that the problem is curtailed early enough. The groups inquire and research on issues that can otherwise risk the health of the population. In essence, the health and social care act of 2012 works to ensure that the population is safe and healthy (Sadek and Sadek, 2004). The legislation has powerful guidelines that shape the manner, which the sector is run. Implementation of the act in the United Kingdom has contributed to excellence in delivering quality services (Nazarko, 2004). Users are enjoying the experience as they are handled professionally and with deserved respect. The idea of introducing penalties for violations of set ethical standards has ensured that users receive quality services.

The Health and social care act helps deliver services to individuals within the United Kingdom. For instance, it allows for assessment of the population to determine its vulnerability to disease. Some diseases can be dangerous and fatal to a population, which necessitates the introduction of procedures to test any disease or condition that may be impending. Failure to conduct such assessments puts the whole population health at risk (Nazarko, 2004). Healthcare services are a basic need, and any slight chance to overlook the sector can lead to fatalities within the population. The health department in the UK is well structured and organized due to the act, which has provided crucial principles on the handling of matters pertaining to healthcare. For instance, the act outlines duties for each body in the healthcare sector (Speed and Gabe, 2013). Such restrictions put facilities on toes to provide the best of care to both children and adults. It is through the legislation that the government controls the exploitation of its citizens by poor service provision in healthcare facilities (Kew and Stredwick, 2008). The policies in place coordinate the running of operations in the healthcare sector to the extent of achieving sustainability. The health and social care act of 2012 is crucial to the population health in the United Kingdom.

Besides assessment of the health status of a population, the act has ensured that people are treated in an equal manner despite their color, originality or ethnic community. Inequalities in the healthcare sector have existed for decades within the country, and there is a need to address the matter by implementing legislation that prohibits any kind of discrimination (Kew and Stredwick, 2008). Prejudice in a healthcare facility can make worsen a patient’s condition, which necessitates for equality in such a context. Other services provided courtesy of implementation of the act include advising clients on the best of habits that promote good health among the population. An informed population is in a better position of preventing a possible outbreak compared to when one lacks information (Pownall, 2013). As such, the health and social care act of 2012 is a law that was put in place to handle inequalities and improve the quality of service provision (Kew and Stredwick, 2008). Equally, the staff employed by the National Health Service work hard to sensitize the community on matters that pertain to healthcare.

The decision-making process of policy formulation is based on some aspects, including the health of the population itself (Nazarko, 2004). In cases where the population health is poor, there is a need to put more effort to restore the desired condition. Financial considerations should be made when devising policies geared towards the promotion of population health in the United Kingdom. Bodies that take part healthcare provision should be tasked with the obligation of promoting good practices (Adams, 2007). Decisions that determine the distribution of resources should be made collectively after engaging various stakeholders in the field.

To sum it up, population health is n important aspect, which affects the economic performance of a country. The paper focuses on the decision-making process that is involved in the formulation of policies. Some policies are set up as a result of a particular incident, while others are not. The study applied the health and social care act of 2012 as an example to illustrate government policies and how they impact operations, especially in the healthcare sector. The act was established primarily to enhance equality and propel excellence in the healthcare sector. The act outlines distinctly roles that each stakeholder must oblige to do for mutual understanding. Equally, the act has promoted good practices within the healthcare sector that have improved the provision of holistic care. In essence, the report is focused on evaluating the Health and Social care act of 2012 and its impact on the provision of standardized services. It is always crucial to devise strategic measures that can promote the welfare of people, especially for healthcare.

Adams, R. ed., 2007.  Foundations of health and social care . Macmillan International Higher Education.

Care Quality Commission, 2012.  The state of health care and adult social care in England in 2011/12  (Vol. 763). The Stationery Office.

Field, R. and Brown, K., 2019.  Effective leadership, management and supervision in health and social care . Learning Matters.

Glover-Thomas, N., 2013. The Health and Social Care Act 2012: The emergence of equal treatment for mental health care or another false dawn?.  Medical law international ,  13 (4), pp.279-297.

Howieson, W.B., 2012. Mission command: a leadership philosophy for the Health and Social Care Act 2012?.  International Journal of Clinical Leadership ,  17 (4).

Kew, J. and Stredwick, J., 2008.  Business environment: managing in a strategic context . Kogan Page Publishers.

Nazarko, L., 2004.  Managing a quality service . Heinemann.

Pownall, H., 2013. Neoliberalism, austerity and the Health and Social Care Act 2012: The Coalition Government’s Programme for the NHS and its implications for the public sector workforce.  Industrial Law Journal ,  42 (4), pp.422-433.

Sadek, E. and Sadek, J., 2004.  Good practice in nursery management . Nelson Thornes.

Speed, E. and Gabe, J., 2013. The Health and Social Care Act for England 2012: the extension of ‘new professionalism’.  Critical Social Policy ,  33 (3), pp.564-574.

Walshe, K., 2012. The consequences of abandoning the health and social care bill.

Williams, R.S., 2002.  Managing employee performance: Design and implementation in organizations . Cengage Learning EMEA.

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Structural changes from Health and Social Care Act (2012)

The Health and Social Care Act 2012 came substantively into force on 1 April 2013, bringing about a wide range of structural changes that would impact on the NHS, public health and adult social care.

Strategic health authorities (SHAs) and primary care trusts (PCTs) were abolished, with responsibility for NHS commissioning passing to NHS England at a national level and clinical commissioning groups (CCGs) at a local level. Local authorities took over control of health improvement functions and Public Health England was established as a national body to oversee health improvement and health protection.

Clinical commissioning groups (CCGs)

211 CCGs were established to replace 152 PCTs and commission urgent and emergency care, elective hospital care, community services, mental health services and maternity services. CCGs would be made of GP practices, but to ensure that a broad range of healthcare perspectives are taken into account, they would seek advice from a range of other healthcare professionals.

NHS England was established to oversee the operation of CCGs and allocate funding to them.

CCGs would control the majority of the overall NHS budget, with specialised services commissioned by NHS England, and health improvement services commissioned by local authorities. Clinical senates were established to provide strategic advice to CCGs, health and wellbeing boards and NHS England on commissioning and decision making on healthcare for local populations. 12 senates were established in England, comprised of a core Clinical Senate Council (a small steering group) and a Clinical Assembly or Forum (a multi-professional group providing support and expertise to the Council). Members include health and care professionals and experts, voluntary sector and patient representative groups. 19 commissioning support units (CSUs) were set up to provide commissioning support services to CCGs, acute trusts, local government and NHS England. These would provide services such as contract management, information governance, financial management, human resources, IT and communications.

Monitor took on its new functions as the sector regulator for the NHS with functions that included:

• running a system of licensing of providers of NHS services
• setting and enforcing requirements to secure continued provision of NHS services
• regulating prices for NHS services through a national tariff, in conjunction with the NHS Commissioning Board
• securing continuity of NHS services provided by companies through a process of 'special administration' and establishing funding mechanisms, to enable trust special administrators to secure continued access to NHS services
• establishing funding mechanisms.

The Cooperation and Competition Panel, which investigated breaches of competition law, became part of Monitor which was given concurrent powers with the Office of Fair Trading with regard to NHS merger decisions.

Public Health England

Public Health England (PHE) was created as an executive agency of the Department of Health. It was given operational independence, but ministers would set its strategic objectives and its functions would be conferred directly on the secretary of state for health by the Health and Social Care Act 2012.

PHE brought together a range of public health functions previously carried out by the Health Protection Agency, the National Treatment Agency, public health observatories, cancer registries and strategic health authorities. It would be responsible for discharging the secretary of state's duty to protect the health of the public, through securing the improvement of the public's health and improving population health through the provision of sustainable health and care services. It would also have a role in ensuring that the capacity and capability of the public health system was maintained, including through supporting local government with their public health duties.

Health and wellbeing boards

Health and wellbeing boards were established by the Health and Social Care Act 2012, to facilitate joint working across health and social care organisations. The boards would also be responsible for producing joint strategic needs assessments and joint health and wellbeing strategies. The Act specified a number of statutory members, including the director of adult social services and director of public health. Additionally, the Act placed a duty on health and wellbeing boards to encourage integration between health and social care commissioners for the benefit of the health and wellbeing of the local population.

Healthwatch England

Healthwatch England was established to act as an independent consumer champion for health and social care service users and to support the local Healthwatch network. It would be responsible for representing the public's views to national bodies, such as NHS England, Monitor, the Care and Quality Commission and the Secretary of State for Health. Its main functions would include supporting local Healthwatch organisations, collecting and collating national information, and charting trends to discern issues of concern and nationally championing these issues for service users and patients. Local Healthwatch organisations were established in every local authority area to take over the work of previous local information networks (LINks). They would provide advice, promote choice and signpost individuals, carers and community groups. They would also have the ability to influence local commissioning decisions, through their statutory seats on health and wellbeing boards.

Part of their remit would be to gather information on local people's experiences of health and social care and feed that data into Healthwatch England, which would use the information to influence national policy. They were also given powers to enter and view services. Some local Healthwatch organisations would also be commissioned by their local authority to provide NHS complaints advocacy services.

The National Institute for Clinical Excellence (NICE)

The National Institute for Clinical Excellence (NICE) was given responsibility for developing guidance and quality standards for social care, using its evidence-based model. This was intended to promote better integration between health services, care services and public health. NICE confirmed that it intended to develop quality standards on the following areas related to social care:

• challenging behaviour in people with learning disability
• managing medicines in care homes
• mental health problems in people with learning disability
• social care of older people with multiple long-term conditions
• transition between health and social care
• transition from children's to adults' services.

Health and Social Care Act 2012.

Campbell F. Get in on the act - Health and Social Care Act 2012. Local Government Association; 2012.

NHS England. Understanding the new NHS. NHS England; 2014.

Ellison J. Public Health England remit letter. Department of Health; 2014.

Healthwatch. What we do. Healthwatch; 2019.

Healthwatch. Healthwatch marks network launch across five events in England simultaneously. Healthwatch; 2013.

East Sussex Strategic Partnership. Overview of local Healthwatch functions. East Sussex Strategic Partnership; 2013.

NHS England. Further Commissioning Support Unit (CSU) managing directors announced by the Board Authority. NHS England; 2012.

NHS Commissioning Board. Developing commissioning support - towards service excellence. NHS Commissioning Board; 2012.

NHS Commissioning Board. Clinical Senates update. NHS Commissioning Board; 2013.

National Institute for Health and Care Excellence. Social care. National Institute for Health and Care Excellence; 2019.

BMA. NHS structures and integration. BMA; 2019.

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• Health and social care

Health and Social Care Act 2012: fact sheets

A series of fact sheets explaining aspects of the Health and Social Care Act 2012.

Applies to England

Overview of the Health and Social Care Act fact sheet

PDF , 130 KB , 2 pages

Health and care structures fact sheet

PDF , 159 KB , 3 pages

Scrutiny and improvements fact sheet

PDF , 157 KB , 2 pages

Clinically-led commissioning fact sheet

PDF , 149 KB , 2 pages

Provider regulation fact sheet

PDF , 138 KB , 2 pages

Greater voice for patients fact sheet

PDF , 159 KB , 2 pages

New focus for public health fact sheet

PDF , 161 KB , 2 pages

Greater accountability locally and nationally fact sheet

PDF , 152 KB , 2 pages

Streamlined arm's length bodies fact sheet

PDF , 141 KB , 2 pages

Support worker regulation fact sheet

PDF , 122 KB , 2 pages

Tackling inequalities fact sheet

Promoting better-integration of health and care services fact sheet

PDF , 160 KB , 2 pages

Choice and competition fact sheet

PDF , 133 KB , 2 pages

Role of the secretary of state fact sheet

PDF , 147 KB , 2 pages

Reconfiguration of services fact sheet

PDF , 120 KB , 1 page

Establishing new national bodies fact sheet

Embedding research as a core function of the health service fact sheet

PDF , 156 KB , 2 pages

Education and training fact sheet

PDF , 151 KB , 2 pages

Case for change fact sheet

PDF , 125 KB , 1 page

These fact sheets explain particular topics associated with the act, including key themes. They include case studies of the policy in action and answers to frequently asked questions about the topic.

The fact sheets were first published in October 2011 and have since been updated to reflect the changes made during the act’s passage through Parliament.

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• Research article
• Open access
• Published: 17 February 2017

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

• E. W. Gadsby 1 ,
• S. Peckham 1 ,
• A. Coleman 2 ,
• D. Bramwell 2 ,
• N. Perkins 2 &
• L. M. Jenkins 1  

BMC Public Health volume  17 , Article number:  211 ( 2017 ) Cite this article

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The 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.

We 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.

Public 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.

Conclusions

Our 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.

Peer Review reports

The UK government elected in 2010 embarked on a wide-ranging program of reforms to the health and social care systems in England. The Health and Social Care Act (2012) formed the centrepiece of the reforms, introducing extensive changes to the organisation, structure and delivery of health services. As part of these changes, key public health functions were transferred from the National Health Service (NHS) to local government councils. This transfer included specialist public health staff and the budget for commissioning a range of public health services, including sexual health services, public health nursing, drug and alcohol treatment, smoking cessation and weight management services. In addition, a national public health agency (Public Health England, PHE) was established, as the national leadership body for public health to provide national campaigns and co-ordinate health protection, and as an active partner in local initiatives where appropriate [ 1 ].

During the reforms, the government highlighted a number of issues that lay behind inadequate population health outcomes. It felt the system was fragmented, lacked integration and synergies across services and had overlapping responsibilities [ 2 , 3 ]. It also felt the system disempowered public health professionals, insufficiently valuing their skills [ 3 ]. Crucially, the government argued that there was an insufficient focus on the root causes of ill health, and pointed to a lack of accountability with regards to outcomes. Issues faced in England chimed with cross-cutting themes that emerged from a review of public health in Europe, notably: the importance of inter-sectoral working, the existence of wide inequalities between and within countries in Europe, and the knowledge gaps around what public health policies and interventions are being implemented where, and which are most effective [ 4 ].

In 2012, a new European health policy framework was developed, to support action across government and society to improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems [ 5 ]. It was in this context that the UK government set out, in the English reforms, to clarify responsibilities and accountabilities, empower people and communities, and focus on the evidence of what works. They wanted a greater emphasis, at all levels, on disease prevention, and a more joined up approach, with clearer leadership. In addition, the need to achieve better results with less money was an undercurrent to the entire health and social care reforms, driven by the government’s aim to reduce their budget deficit.

Prior to the reforms in England, Primary Care Trusts (PCTs) were the NHS bodies responsible for commissioning – strategic planning and purchasing - most health services, including for public health [ 6 ]. Until 2011, PCTs also directly managed the vast majority of NHS community health services, such as district nursing, health visiting and children’s services. In 2013, PCTs were abolished and replaced by a new NHS commissioning architecture, locally led by Clinical Commissioning Groups (CCGs), and nationally led by a new independent NHS commissioning board (NHS England) [ 7 ].

Within PCTs, public health specialists tended to provide a lead role in developing strategies for meeting local health needs, and specialist clinical and public health advice to inform PCT commissioning. Whilst public health was (and remains) an inter-organisational function, with much close working between PCTs and local councils, funding remained predominantly from NHS sources, with most decisions about services and expenditure taken within an executive decision-making framework by Directors of Public Health supported by PCT Boards [ 6 , 8 ].

Public health services are now funded by a public health budget, separate from the budget managed through NHS England for healthcare. This budget is decided by the Department of Health (DoH), and managed by PHE. PHE funds public health activity either through allocations to upper-tier and unitary councils, by commissioning services via NHS England, or by commissioning or providing services itself. Most locally delivered public health activities are now commissioned or provided by local councils. The structure of local government in England is complex: there are 27 areas where services are split between upper-tier county councils (taking responsibility for social care, education, transportation and strategic planning), and smaller district councils (covering e.g. housing, leisure, environmental health and planning), and there are 125 unitary councils that provide the full range of services. All of these councils are run by elected councillors, usually affiliated to a political party, who represent and engage their local population, make key decisions, contribute to policy/strategy review and development, and conduct overview and scrutiny roles. Councils have the freedom to innovate and to make changes locally, under the ‘general power of competence’, introduced by the Localism Act 2011 [ 9 ]. There are important differences, then, in the context in which local public health commissioning is now done.

The Health and Social Care Act also introduced Health and Wellbeing Boards (HWBs) as statutory sub-committees of local councils. These boards were intended to bring together the key NHS, public health and social care leaders in each local council area to work together to co-ordinate commissioning of their services. They are thus an important part of the new health commissioning landscape [ 10 ].

A House of Commons Health Committee inquiry on public health post-2013, launched October 2015, is starting to raise some important issues related to the structures, organisation, funding and delivery of public health following the reforms [ 11 ]. However, to date, little academic attention has been paid to the impact of the reforms on public health commissioning in England. This article examines key changes to the public health system following the reforms, and explores the broad function of commissioning for health improvement within the new system. It highlights some important changes in the way public health commissioning is now undertaken, in who is doing it, and in what is commissioned. It draws on findings from a 3-year research study funded by the DoH, which examined the impact of structural changes on the functioning of the public health system, and on the approaches taken to improving the public’s health. The article critically examines these findings in the context of the intentions of the reforms to create a more joined-up system with clearer leadership and greater opportunities to improve population health.

The PHOENIX study was a 3-year research project to examine the impact of structural reforms on the functioning of the public health system in England. It was an exploratory study that took place from the time of transition (April 2013), and so could explore the ways in which the planning, organisation, commissioning and delivery of health improvement services were changing over time as the new structures bedded in. One of its objectives was to examine approaches taken to commissioning within the new system, using obesity as a focal topic.

The study incorporated multiple methods. In a scoping review [ 12 ], we analysed policy documents and responses to the reforms from key stakeholders [ 13 ], developed a picture of how the new structures were developing, and collated demographic and other data on all 152 upper-tier and unitary local councils in England. This review identified the key themes to follow up on in the next phase of the research. It also enabled the purposive selection of local councils for later case study research, conducted from March 2014 to September 2015, in five areas. The areas were purposively selected for maximum variation across a a range of characteristics related to the councils and the populations they serve (including council type, size, urban or rural location, varied socio-demographic and economic circumstances, obesity prevalence and different political control) in order to provide a diverse range of cases. The five areas (described in Table  1 ) encompassed 13 different councils, including unitary, upper-tier and a sample of lower-tier (district) councils, some of which had a variety of different sharing arrangements. This enabled an examination of multiple perspectives and inter- and intra-organisational relationships.

Within the case study areas, 103 semi-structured interviews were conducted (see Table  1 ) with 36 council public health staff; 18 elected members; 25 council non-public health staff; 13 provider organisation staff; six CCG staff and three other staff at regional levels. Three members of the research team were allocated across the case study sites to enable each researcher to develop a deep understanding of and good relationships within each area. Fifteen meetings were observed and documentary evidence was collated to enrich our understanding of the case study areas. A further five interviews were conducted with key informants outside of the case study areas, particularly to explore national and regional level issues and relationships with/within PHE.

In the autumn of 2015, a web-based questionnaire was sent to all Directors of Public Health (DsPH), and to councillors in all 152 upper-tier and unitary councils who had a public health brief. Usable responses were received from 49% of DsPH and 32% of elected members. The questionnaire was broadly a repeat of a survey conducted the previous year (not reported in this paper). The distribution of responses from local councils was highly representative overall. Data was analysed using SPSS.

Qualitative data was analysed on a case and theme-based approach, using NVIVO 10. Multi-investigator, multi-site and multi-method triangulation was used in an ongoing and iterative process of bringing together and interrogating the data. Reflexive, narrative accounts of each case study area were shared with the research team, which was made up of experts in public health, local government, ethnography, and public policy. Rich interpretations of emergent themes across the cases were developed collaboratively, paying particular attention to roles and relationships, power/autonomy, and decision-making processes. Analysis drew on a number of integrative theoretical frameworks, employing concepts and ideas drawn from a number of different paradigms [ 14 , 15 ]. Ongoing analysis of the data allowed shifts in focus according to the interplay between theory, concepts and data, enabling sensitivity to the constantly changing field of study.

Ethical approval was granted by the university research ethics committee, and research governance approvals were obtained for each case study site.

Throughout analysis, commissioning was considered as one of the broad aspects of public health activity. As a theme, it included identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance. Our research set out to examine the context for commissioning, the people/organisations involved in commissioning activities, the processes involved, and any evidence of things changing.

The context for commissioning

The transfer of public health staff and resources into local councils from PCTs was far from straightforward, and often accompanied other system reorganisations. For instance, in one of our case study areas, staff in a PCT were separated into a council public health team, one of three CCGs, or into a provider trust. One children’s public health commissioner who was formerly in the children’s joint commissioning team in the PCT with commissioning responsibilities for the whole of the 0–19 pathway, was transferred to a council team. Her former commissioning responsibilities were split amongst different organisations, and she was now responsible only for certain elements of the healthy child programme. She explained the resulting confusion:

“… It has caused fragmentation of the system and certainly for the 0–19 pathway or services for children, you know, the health services for children. It has meant that different parts of the system are now responsible for commissioning different elements of it …, which is challenging” (senior public health commissioner, council, site B).

This also had implications for the sharing of information between health and council commissioners, which this officer described as being “much more difficult for us now”.

Some public health staff chose to join PHE or NHS England, and some became part of new commissioning support organisations. There was much confusion over where staff should be transferred to (sometimes depending on the proportion of their time spent on service commissioning versus service provision), and around the organisation of budgets. There were instances where this tested relationships between councils and CCGs.

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 which sought to streamline their organisations and reduce staffing costs. The positioning of public health teams within councils varied. Our survey found that 26% ( N  = 73) of the public health teams were distinct public health directorates; 52% were sections of another directorate; and 22% had other arrangements, including merged, distributed and mixed models. DsPH also had different levels of access to key council decision-making bodies (53% of DsPH respondents were members of the council’s most senior corporate management team), and different line-management structures (47% said that they were managerially responsible to the council’s chief executive; 53% were managed by a range of other directorate heads). Consequently, DsPH were not always in the best place for strategic influence in the council.

Commissioning processes and people involved

Decision-making within councils was found to be very different to that within PCTs. Decisions about how to spend money were subject to a greater range of decision makers and wider consultation, both across the council and amongst the public, than before. Elected members are the key decision makers within councils; the role of officers, including those in public health, is to support them. Elected members, therefore, were influencing the priorities and actions of the public health team, sometimes overtly and sometimes more subtly. 92% of elected members responding to our survey ( N  = 38) said they felt always able (45%) or quite often able (47%) to influence the priorities of the public health team. In our case studies, we saw how this influence might operate more subtly, perhaps according to the ideologies and interests of the elected member, or the politics of the council. For instance, in one Conservative-led council, the elected member explained that he would have a very difficult job persuading his cabinet to significantly increase spending on smoking cessation: “They’re not particularly interested in it, they think … ‘oh well if people smoke themselves silly, let them smoke themselves silly’” (elected member, council, site A).

Compared with the NHS, local councils take different approaches to prioritisation and commissioning, influenced in part by over 15 years of implementing ‘Best Value’ Footnote 1 . The processes of commissioning (and new procurement laws) within a council have had to be learned by incoming public health staff. At the same time, public health staff have tried to educate councillors in public health commissioning.

Several commissioning officers who had worked within councils prior to the reforms (e.g. in adult or children’s social care directorates) and who moved, following the reforms, into the public health teams, talked about differences they observed in how commissioning was done. One, referring to her incoming public health colleagues, explained:

“We were faced with a lot of ignorance about commissioning - local authority style commissioning and business processes - amongst our colleagues… I was shocked actually by the lack of understanding of what we had been doing or what we did [as local authority commissioners]” (commissioner, council, site B) .

Another talked about the differences between commissioning in PCTs and commissioning in the councils. She explained that “public health has commissioning responsibilities now in a way that they didn’t in the old PCT”. She described commissioning in the former PCTs as comparatively less ‘robust’, with less accountability, and less scrutiny of performance and outcomes data:

“ there’s much stronger scrutiny in local government and that’s all areas of business and it’s something that we’ve had to really work with our providers in NHS specifically around understanding” (commissioner, council, site A) .

From the point of view of providers, however, the sometimes rather narrow outcomes-based scrutiny that services were now subjected to was not always appropriate for complex public health interventions. For instance, the provider of a range of obesity prevention services in one of our case study areas complained that the focus on outcomes in terms of body mass index reductions belied the fact that most of their time and resources were spent on engaging communities and developing relationships with schools and others. The outcomes of this type of activity, however, are impossible to measure.

Having a distinct public health grant for the first time enabled DsPH to take a different approach – a more strategic approach - to the allocation of the public health budget. A public health officer in one of our sites described how, in the PCT, they were sometimes left ‘scrabbling’ around for funds, when public health priorities and PCT priorities were not always well matched. However, with a ring-fenced budget, they were able to plan how best to match spending against their local priorities. The leader of a council in site A explained how they were prepared to completely shake up the way in which the public health grant was spent: “ We’ve got to start at reviewing; is that delivering to the right priorities or not? Is it value for money or not? And what should we stop doing and what should we start doing? ” Indeed, this process of whole-scale service reviews for specific areas (such as obesity) was demanded by councillors in all of our case study areas. For public health officers, this sometimes gave them the freedom to pursue quite different approaches.

Decision-making across the local system following the reforms was intended to be more co-ordinated. However, with commissioning responsibilities now fragmented between NHS England, PHE, local councils and CCGs, our research found that co-ordination was proving to be difficult. Moreover, the lack of clarity about responsibilities sometimes led to delays in the commissioning of services, and/or tensions in the relationships between organisations. Commissioning across an obesity pathway, for instance, involves councils (for broad obesity prevention and non-intensive weight management services), CCGs (for specialist obesity services) and NHS England (bariatric services) [ 17 , 18 ]. Across England, we know that there are significant gaps in this pathway, with a particular lack of specialist obesity services [ 19 , 20 ]. Following the reforms, there was a great deal of confusion about whose responsibility it was to commission these services.

It is clear that, as with many public health interventions, if weight management and obesity prevention services are to achieve their objectives, primary and community care providers play a vital role. The presence, absence, type and success of health improvement services commissioned by councils have important implications for NHS work. However, there is now a greater disconnect between public health officers and NHS commissioners. In response to our survey, 48% of DsPH ( N  = 69) said they felt ‘less able’ to influence local CCGs than before the reforms. In our case study sites, we found that evidence of meaningful engagement between public health teams and CCGs was limited. This HWB chair felt that CCGs had become disengaged from public health:

“ I think we’ve got to persuade the CCG that, in particular, public health is everybody’s business, it’s not just the local authority’s business. … they see public health as a separate entity at the moment, and not part of an integrated health economy” (Chair HWB, council, site C) .

HWBs were meant to be the mechanism for co-ordinating commissioning across NHS, social care and public health at the strategic level. Our survey found that amongst DsPH ( N  = 65), 48% felt the HWB was ‘definitely’ instrumental in identifying the main health and wellbeing priorities, and 45% felt it had ‘definitely’ strengthened relationships between commissioning organisations. However, less than 5% felt that the HWB was ‘definitely’ making difficult decisions, and only 28% felt that it had ‘definitely’ begun to address the wider determinants of health. A further complication with co-ordinating across the system and addressing wider determinants is that in two-tier councils, many of the functions that public health are expected to work across are based in multiple lower-tier district councils. Public health officers must therefore build relationships with a greater number of different organisations, all with their own priorities and ideas. In addition, these district councils often have a limited voice on HWBs. It is perhaps partly for this reason that some HWBs were not seen to be significantly engaging with the public health agenda. As this HWB chair explained:

“We have a very strong focus on integration, Better Care Fund – all that side of things. I’m conscious sometimes of an element of criticism … there’s always a challenge to say, ‘Are you actually thinking enough about long term determinants and all the sort of public health agenda’ …” (Chair HWB, council, site A).

What has changed?

Our research suggested that, as a result of the reforms, public health commissioning was changing on a number of levels. Firstly, money was being used in different ways. One indication of this was the way in which the ring-fenced public health budget was being used to invest in other departments in the majority of councils (see Fig.  1 ). Given the huge cuts councils were having to make, most DsPH felt that, now the public health budget was contained within the council, it was expected to contribute to the overall savings they needed to make. Many seemed reconciled that the budget would now be used to fund other services – in many cases, services that would have been cut (e.g. children’s centres) had public health funding not been available. And in our case studies, public health officers talked about the opportunities this sometimes presented, in terms of embedding public health activities and objectives within other council services and providing more joined-up ways of thinking and working.

Use of public health budget to invest in other council departments in previous 12 months

Secondly, there were many changes being made to the commissioning of health improvement services (see Fig.  2 ). The move to local government prompted public health commissioners to look at services and contracts anew. In addition, councils tended towards shorter contracts and more frequent retendering of services than the NHS. All our respondents had started the process of retendering within 2 years. But we also saw the majority of responding authorities ( N  = 64–67) having set up new services (73%), changed provider of existing services (90%), re-designed existing services (94%) and de-commissioned services (69%). In our case study areas we saw that extensive commissioning changes were sometimes occurring as a result of changes in local area arrangements, for instance, where several areas (former PCTs) were brought together into one (council). Other commissioning changes, however, were as a result of service reviews that were very critical of service outcomes.

Changes made by councils to services commissioned under public health budget in last 12 months

Our surveys asked for more information about changes that were being made to obesity commissioning. DsPH commented that they were wanting to move away from ineffective schemes, increase their focus on children, use new providers and create a more integrated pathway. All these changes were resulting in insecurity in the provider landscape.

Finally, there were changes to the size and profile of the public health teams responsible for commissioning health improvement services. DsPH were asked whether there had been changes in the last 12 months to the size and composition of their public health team. 28% ( N  = 72) reported that they had fewer public health specialists. 15% reported they had more business managers/commissioning support staff, and 22% ( N  = 54) said they had more ‘other’ staff (not falling into the DPH, specialist, analyst or commissioning support categories). In our case study sites, public health officers talked of the need to address skill gaps within their team in response to working in the new environment. In one of our sites, for instance, the public health commissioning team (made up of non-public health specialists) had been significantly bolstered. The team of public health specialists had been correspondingly reduced.

It was not easy to tell, at this juncture, whether these observed changes in commissioning had resulted in a significantly different set of activities being commissioned. However, there were early signs of some general shifts occurring. In three of our case study areas, we observed a shift towards the commissioning of more holistic ‘healthy lifestyle’ services, bringing together weight management, smoking cessation, alcohol reduction, sexual health services, and so on. In two of our councils, we saw a shift (at least in rhetoric) towards ‘whole council’ approaches, for instance, where they were seeking to address a broader range of factors influencing obesity, particularly by working across council departments. We witnessed a greater recognition of public health objectives and expected outcomes in a wider range of council services as a result of public health investment. And we saw public health staff working hard to influence the wider workforce. Particularly during the transition phase, as public health were settling into their new homes, a number of programmes including learning events, information sharing, and engagement events were targeted at elected members and non-public health officers across the council.

The reforms expressed a clear intention to simplify and streamline a previously complex, fragmented system. The transfer of public health responsibilities into local councils was to ensure that public health outcomes were embedded across a council’s functions. The creation of HWBs was to ensure strategic direction across organisations.

The functions of the now extinct PCTs were spread across CCGs, councils and provider organisations, creating a more complex organisational picture than before the reforms, with more complex accountability and governance structures. Moreover, there was continued upheaval in the system, with elements such as CCGs and public health teams merging, the PHE regional tier ‘downsizing’, and local councils constantly restructuring as they tried to cope with substantial budget cuts. Fragmentation is a problem common to many health systems, and is a condition related to the tendency within health care planning to focus and act on the parts without adequately appreciating their relation to the evolving whole [ 21 ]. There is a constant challenge to create a system focused on relationships across the whole – whole people, whole systems, whole communities. It is often these relationships across the whole that suffer in the context of financial restraint and continual change [ 22 ].

The move of public health into local councils in England created a new working environment for commissioners, public health practitioners and providers. Our findings have demonstrated how, in this new environment, existing public health capacity has been both freed and stifled. Public health professionals have the opportunity to take on a more significant role in shaping local places, but will need to find a balance between ‘service’ public health and academic ‘social medicine’ [ 23 ].

The considerable literature on decentralisation suggests that the transfer of authority and resources to local government might offer significant opportunities to improve access to health and other care services, to provide services that are better aligned to needs and local preferences, and to allow for increased flexibility and transparency [ 24 – 26 ]. However, the reforms in England simply moved public health responsibilities at the local level from executive decision-making bodies (PCTs) to democratically governed councils. Whilst PCTs had the same ‘local’ focus as councils, they were historically more directly accountable to central government, and, with a few exceptions, were poor at developing local ‘bottom-up’ methods for making NHS services more user-responsive [ 27 ]. Councils, on the other hand, have been subject to a longer experience of competitive tendering and service commissioning than the NHS [ 28 ], and tend to have a more structured approach for community engagement and user-involvement embedded in their organisational culture [ 29 ]. As a result, there appears to have been a shift in how public health commissioning is performed, from a more specialist-led investment approach to a more ‘business’-orientated approach adopted by many local councils, using best value frameworks.

In the new environment, there seems to be more opportunity for variation across the country in what activity is commissioned, and in who provides it (as well as how, where and to whom). The Localism Agenda [ 9 ] gives councils more freedom to innovate, to both drive down costs and meet local needs [ 30 ]. Considerable discretion was afforded to individual councils to interpret the full and detailed scope of their new functions and services [ 31 ]. This was important, given the independence of councils as democratic organisations, but it means that public health decision-making is now less amenable to central government control.

In the absence of strong central control, it is important to question the extent to which local problems can be solved locally without risking geographical inequity of services which underpin basic human rights [ 32 , 33 ]. For the next couple of years, the annual public health budget devolved to local government in England will be around £3.3 billion (reducing by an average of 3.9% every year in real terms until 2020) [ 34 ]. Prior to the reforms, this budget would have been spent by PCTs, who were accountable for that spend to the DoH, via regional NHS authorities (now abolished) who were mainly concerned with overall NHS expenditure and financial sustainability of NHS healthcare services. Following the reforms, whilst the public health outcomes framework gives a clear sense of outcomes the DoH expects to see, the accountability for spending money is much weaker. Beyond a basic report to the Department on how the budget has been spent, there is very little role for formal state-driven accountability. In a way most uncharacteristic of the NHS, PHE has emphasised that it is there to support local councils, not performance manage them. Instead, there is a reliance on sector-led improvement, whereby councils review and support each other’s performance [ 35 ]. In addition, public health commissioning is coming under much closer scrutiny from elected members within the local council. Our research supported the idea that we can expect to see increasing variation in services, but it is far from clear what impact this will have on variations in outcomes.

Public health officers moving from the NHS to local councils have sometimes struggled to adjust to this different relationship with central government. From the point of view of commissioners, the lack of guidance and clarity from Government was often found to be unhelpful. In particular, public health officers expressed the need for more timely information, for instance, regarding responsibilities for commissioning across the fragmented system, or how the in-year budget cuts would be implemented [ 36 ]. In the absence of detailed information, public health teams were sometimes forced to make commissioning decisions based more on expediency than on need. In the new system, the DoH is defined as the ‘system leader’, improving people’s health and wellbeing through its stewardship of the public health system [ 37 ]. The concept of health stewardship implies a broad over-arching responsibility over the functioning of the system as a whole and, ultimately, over the health of the population [ 38 ]. However, we suggest that central government in England has yet to resolve some important stewardship issues, particularly around its role in securing resources, balancing competing interests and demands, and assuring delivery in the context of localism and the move of public health into local government. Moreover, there was little in our research to suggest that PHE have sufficient capacity, or have yet developed the strong relationships required, to provide meaningful support to local partners in the delivery of their vision.

Public health officers have also had to adjust to different roles and relationships relative to other actors at local level. Directors of public health were previously key decision makers on the executive boards of PCTs. Whilst they were often the first to be pushed back if cuts were required or budgets exceeded, DsPH had clear authority with regards to public health prioritisation. Following the reforms, they are expert advisers to elected members. Leadership for public health is more dispersed; decision-making is now more complex, and arguably subject to greater political ideology and personal interest. There may also be unforeseen consequences arising from the outcomes-based scrutiny of complex public health interventions, and from increased insecurity within the provider landscape. Many public health interventions require a long time-frame in which to bring about significant population health improvements. This doesn’t sit well with the short-termism of contemporary politics. As local councils struggle to cope with tighter budgets, public health officers may find it harder to convince their elected members of the added value of some of the public health services they commission.

Our research has highlighted the huge amount of change occurring in the commissioning (and decommissioning) of health improvement services in England. Whilst it will be important for the wider health system that key public health services are protected and improved (for instance, in smoking cessation, weight management and sexual health services), the public health specialists will need to capitalise on bringing about positive change through closer integration with the strategy and activity of the council. Commissioning for health improvement requires commissioners to focus on the modifiable determinants of health, taking a pro-active approach to improving individuals’ life chances and reducing social inequalities, rather than waiting until people are already ill and commissioning reactively. Local councils, due to their wider scope and responsibilities, are better placed than the NHS with its largely clinical orientation, to address a broad range of determinants, such as lifestyles, community, local economy and activities [ 30 ]. Our research, like the many case studies highlighted in a range of Local Government Association reports [ 39 – 42 ] has identified a range of positive examples where stronger and more direct public health involvement and influence across councils has brought about new opportunities. In their new ‘home’, and with the right support from their council, public health officers can be afforded the freedom to approach public health challenges in new ways. Local councils are also more adept than NHS organisations at broader level consultation and community engagement, which might afford new opportunities in line with the Ottawa Charter recommendations for public participation and empowerment [ 43 ].

The NHS continues to have a vital part to play in population health improvement, and the reforms hoped to bring about improved synergies between public health, NHS and social care. However, with public health moving ‘arms-length’ to the NHS, both health services commissioners and providers are becoming more remote to the local public health systems. Moreover, the vital co-ordination role of HWBs is not always working well locally [ 10 ]. Some health improvement services could, as a result, end up being disconnected from each other and from wider support. Similarly, services that are crucial to the achievement of health service objectives (such as reducing premature mortality from the major causes of death), but which are commissioned or provided by the council (e.g. weight management, smoking cessation and alcohol services), are at risk of being cut or changed. Our research has highlighted that there is much change in the way public health commissioning is done, who is doing it, and what is commissioned. Time (and further research) will tell if these changes are to result in improved outcomes and reduced inequalities. However, until there is a strong sense of shared ownership across local systems, and ‘whole system’ commissioning at local level, any opportunities afforded by the reforms to the public health system might be outweighed by the challenges of fragmentation and budget cuts.

We found that the system created by the reforms was confused, continually changing, and - from the point of view of commissioning - more fragmented than before. In some ways, the move of public health into councils has brought about some of the opportunities associated with decentralisation – in particular, allowing for increased flexibility. However, most public health commissioners were essentially moved from one local organisation (NHS), to another (council), so the comparisons with decentralisation are limited. In this new local environment, former public health capacity has been at the same time freed and stifled. Public health commissioning is being more strongly influenced by a new set of decision-makers in the form of democratically elected councillors, with their own local knowledge, ideologies, and experiences. Meanwhile, many councils are bringing a more business-oriented approach to bear on public health commissioning, with greater scrutiny of outcomes in relation to spend. This is challenging the public health specialists and provider organisations, and changing the shape of health improvement services. Whilst we can expect to see increasing change and variation in services across England, it is far from clear what impact this will have on outcomes and on variations in outcomes.

The Duty of Best Value makes clear that councils should consider overall value – including social value – when considering service provision. Under the general Duty of Best Value, local authorities should “make arrangements to secure continuous improvement in the way in which its functions are exercised, having regard to a combination of economy, efficiency and effectiveness” https://www.gov.uk/government/publications/best-value-statutory-guidance--4.

Abbreviations

Clinical Commissioning Group

Department of Health

Directors of Public Health

Health and Wellbeing Board

National Health Service

Primary care trust

Public Health England

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Acknowledgements

We are grateful to our case study sites for allowing us to spend so much time with them and for being so open in discussing their work. We are also grateful to the survey and interview respondents for giving up their valuable time to respond to our questions. The project’s stakeholder group have provided valuable guidance and support throughout the research.

This research on which this article is based was funded by the UK Department of Health. The views expressed are those of the researchers and not necessarily those of the Department of Health.

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Data will not be shared due to the difficulties of ensuring anonymity of sites and individuals.

Authors’ contributions

SP managed the research on which this article is based. EG, AC, DB, NP and LJ carried out the research. LJ conducted the analysis of the surveys. EG, AC, DB, NP and SP were involved in analysing the case study data. EG drafted the manuscript. EG, SP, AC, DB, NP and LJ helped to interpret the data and edit the manuscripts. EG, SP, AC, DB, NP and LJ approved the final version of the manuscript.

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The authors declare that they have no competing interests.

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Ethics approval and consent to participate

Approval was sought and granted from the University of Kent’s School of Social Policy, Sociology and Social Research Ethics Board (SRCEA No. 112), and research governance approval was obtained for each case study site in respect of NHS interviewees from the Health Research Authority (15 July 2015/182754). Written, signed consent was obtained from the heads (leaders and/or chief executives) of all local councils within the case study areas and every individual interviewed within the study.

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Gadsby, E.W., Peckham, S., Coleman, A. et al. Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?. BMC Public Health 17 , 211 (2017). https://doi.org/10.1186/s12889-017-4122-1

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DOI : https://doi.org/10.1186/s12889-017-4122-1

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Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening

Jonathan hammond.

1 Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK

2 School of Health Sciences, University of Manchester, Manchester, UK

3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK

Thomas Mason

4 Manchester Centre for Health Economics, University of Manchester, Manchester, UK

Matt Sutton

5 Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK

Nicholas Mays

6 Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

Anna Coleman

Pauline allen.

7 Health Services Research Unit, London, UK

Lynsey Warwick-Giles

Kath checkland, associated data.

bmjopen-2018-024156supp001.pdf

Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms.

Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25–64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome—unassisted birth rates—largely unaffected by HSCA changes.

Interviewees identified that cervical screening commissioning and provision was more complex and ‘fragmented’, with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups.

Conclusions

Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.

Strengths and limitations of this study

• Few studies have investigated in detail the impacts of large-scale health system change.
• This study combines detailed qualitative data exploring impacts on the system with quantitative exploration of important outcomes, supporting causal inference.
• Based on qualitative findings, we developed a quantitative measure for assessing the extent of disruption to the English NHS commissioning system as a result of the 2012 Health and Social Care Act.
• We found that cervical screening rates decreased more post-Act in areas that had experienced higher levels of disruption.

Introduction

Structural reorganisations of publicly financed healthcare systems, driven by central government or other state agencies, are frequently employed with the objective of improving healthcare delivery, and thus population health outcomes, while reducing or containing costs. 1 However, such endeavours can be disruptive and expensive. 2 It is important to understand what possible impacts these reorganisations have in order to understand their value. 3

In the English National Health Service (NHS), attempts to evaluate the impact of reorganisations have typically used operational indicators (eg, bed availability, number of staff) and measures of clinical activity because their improvement was the stated goal of government policy (eg, The NHS Plan 4 ). Other studies have attempted to assess the impacts of reforms by measuring their effects on prices, quality and quantity of provision. 5 Most studies have relied on quantitative analysis of measures that were explicitly targeted by policy reforms. There is a need for approaches which combine qualitative and quantitative methods to generate a deeper understanding of the impacts of structural reorganisation. 6

The most recent structural reorganisation of the English NHS, the Health and Social Care Act 7 (hereafter ‘HSCA’ or ‘the Act’), was introduced in April 2013 and included wide-ranging changes to the health services commissioning system. We explore whether changes to the commissioning of cervical screening services resulting from the Act affected uptake. This analysis uses a relatively novel mixed methods approach. An initial ‘bottom-up’ qualitative analysis allowed us to identify problematic issues associated with the HSCA for those working locally in the health service commissioning system. This process highlighted the disruption to established commissioning arrangements and cervical screening as a clinical activity, which may be specifically affected by this disruption. We then developed a quantitative investigation to explore this more fully. Together these analyses allow us to infer causation.

The HSCA and changes to cervical screening commissioning

The HSCA is regarded as one of the most wide-ranging legislative reforms in the history of the English NHS. 8  Primary Care Trusts (PCTs), 152 organisations previously responsible for the commissioning of primary, community and secondary health services from providers on behalf of local populations, were abolished. Their commissioning functions were split between three groups of organisations: 211 (now 195) newly created Clinical Commissioning Groups (CCGs), membership organisations constituted by general practitioner (GP) (family doctor) practices, given responsibility for commissioning services for their local populations; NHS England (NHSE), a new arm’s-length governmental body with responsibility for authorising and assessing CCGs and commissioning some services at a national level; and top-tier and single-tier elected local authorities, which took responsibility for the majority of public health services for the first time since 1974. In addition, Public Health England (PHE) was created as an executive agency of the Department of Health, to unify the diverse public health profession and provide expert support for local public health services.

In some service areas, the transfer of commissioning responsibilities was relatively straightforward (eg, the commissioning of routine orthopaedic surgery was passed from PCTs to CCGs with minimal alteration to the bundle of services involved). In other service areas, the transfers were much more complex, particularly the commissioning of national screening programmes and sexual health services, as a result of changes to public health commissioning. Pre-HSCA, national screening programmes and sexual health services were both commissioned by PCTs. Cervical screening was largely provided by GP practices, which received additional funding linked to levels of activity, 9 but some women opted to have their cervical smears in PCT-commissioned sexual health clinics. Post-HSCA, responsibility for public health services, including most sexual health services, was transferred to local authorities. The underlying programme theory (ie, the explicit expectation about how the policy would work 10 ) was that local authorities would be better placed to address the wider determinants of health and well-being than the NHS because they could link public health services with their existing responsibilities, such as for transport and housing. 11 NHSE took responsibility for commissioning national screening programmes. 8 NHSE’s regional teams are responsible for commissioning screening programmes, supported by PHE staff ‘embedded’ within NHSE’s screening and immunisation teams. 12 There was no identifiable underlying programme theory for this specific change to screening programme commissioning. However, it is notable that, in contrast to the emphasis placed on localism associated with the creation of CCGs and with the transfer of public health to local authorities, screening commissioning became more centralised as a consequence of the HSCA.

Table 1 shows the organisations with responsibilities of relevance to the commissioning of sexual health, including cervical cancer screening services, pre-HSCA and post-HSCA. It illustrates how responsibility for such services, previously commissioned by PCTs, was split between different agencies. This increased complexity and fragmentation of responsibilities had the potential to disrupt service commissioning. 13

Organisations of significance to the commissioning of cervical screening pre-HSCA and post-HSCA

GP, general practitioner; HSCA, Health and Social Care Act 2012.

This analysis comes from a study designed to foster emergent interplay between qualitative and quantitative data analysis. 14 15 The focus on cervical screening was not established at the project design stage but driven by the initial qualitative interview findings related to sexual health commissioning arrangements and screening activity post-HSCA. These findings prompted us to consider a quantitative exploration of predictions made by interviewees relating to potential changes in cervical screening activity.

Study context and design

This analysis forms part of a longitudinal project, with data collected between January 2015 and December 2017, into the effect of the HSCA on the commissioning system in England. We combined a qualitative and quantitative exploration of the commissioning of services in two large, socioeconomically diverse metropolitan areas of England with a national level quantitative study of commissioning outcomes. We used a sequential mixed methods approach in which initial qualitative data collection and analysis were used to shape an ensuing quantitative analysis using routinely available data. We therefore present the qualitative and quantitative methods and findings in the order undertaken, and integrate them in the ’Discussion' section.

Patient and public involvement

Our interest in exploring the impact of systemic commissioning change on cervical screening rates was driven initially by concerns expressed by interviewees about potentially negative consequences for patients relating to new arrangements. Patients were not directly involved in the design of, or recruitment to, the overarching project, but an advisory group including a patient representative met regularly throughout the project and played an important role in supporting its development. We presented our initial qualitative findings relating to cervical screening, and early ideas for developing a mixed methods investigation, to our advisory group and were encouraged by our patient representative to pursue this. The results of the broader project were disseminated to participants, and the advisory group, in the form of a series of short reports focusing on specific areas of commissioning and the final report.

Qualitative component

Setting, participants, sampling and data collection.

The qualitative component took place between March 2015 and August 2017, focussing on two metropolitan ‘health economies’ covering a geographical population and a group of commissioning organisations and providers with close operational links. Across both areas, we conducted 143 interviews (each typically an hour in length), 93 of which related to sexual health commissioning, with clinical and non-clinical commissioners, managers, clinicians and senior administrative staff from CCGs, local authorities, service providers and third sector organisations. Organisations and participants were sampled purposively for variation in type and role. We identified participants through organisational websites, personal contacts and through ‘snowballing’ in which we asked participants to recommend other potential participants. Additionally, 8 hours of meetings of an interorganisational sexual health coordinating group involving sexual health commissioners and providers were observed in one of the areas.

Interviews focused on the commissioning system pre-HSCA and post-HSCA, exploring continuities and changes to personal and organisational roles, key issues and challenges, accountability and performance management, interorganisational relationships and communication and commissioning decision-making. Interviews took place either in person (usually in participants’ offices) or over the telephone. All interviews were audio-recorded and all interviewees were provided with written information about the study before consenting to participate.

Data analysis

Audio recordings of interviews were transcribed verbatim, and observational notes from meetings were produced contemporaneously. Transcripts and observational notes were imported into NVivo V.10 software and analysed thematically by JH and AH. 16 This involved repeated readings of transcripts to become sufficiently familiar with their contents, identifying initial codes and coding chunks of data, searching for themes and then iteratively defining and reconstituting themes. Our findings (see below) contained some predictions made by participants regarding changes in cervical screening activity as a consequence of the Act. This prompted us to explore these predictions in a quantitative analysis, which we now describe.

Quantitative component

Interviewees identified that the HSCA had introduced confusion over responsibility for the commissioning of cervical screening services, and had increased variability of provision. They hypothesised that cervical screening rates might be reduced by the new commissioning arrangements; this prompted discussions among the research team and advisory group about developing a way of testing these predictions quantitatively as far as routine data would permit. As the Act had been implemented in all areas simultaneously, removing the scope for a quasi-experimental approach, we sought to identify a measure of variability in the extent to which the Act would have been expected to make commissioning more difficult in each area. One of the features of the post-HSCA system was that some, but not all, CCGs were established which crossed local authority boundaries. Some CCGs related to as many as three separate local authorities. Local authorities were now directly involved in sexual health services commissioning. Findings revealed that CCGs experienced extra challenges when they had to engage with more than one local authority. This suggested that the burden of additional interorganisational coordination might have consequences for commissioning.

As each local authority developed its own approach to cervical screening in its local sexual health clinics, we explored the possibility that GP practices located in CCGs which had to work with more than one local authority might experience lower screening rates compared with practices located in CCGs which had only to deal with one local authority. We compare the demographic characteristics of these two groups in table 2 . The 89 CCGs dealing with more than one local authority had a slightly older population profile than the 119 CCGs which dealt with only one local authority but were otherwise highly comparable.

Clinical Commissioning Group (CCG) demographic characteristics depending on the number of local authorities that the CCG needs to work with

Because cervical screening rates may be influenced by other factors that we cannot observe and may change over time in different ways between the two groups of CCGs, we also compared screening rates with an outcome that was unlikely to have been affected by the introduction of the HSCA. We used unassisted births (ie, uncomplicated deliveries which did not require any intervention) as a percentage of all maternal deliveries, since the commissioning of maternity services was largely unchanged by the Act.

We applied a triple-difference approach. The triple difference represents (the change over time in cervical screening rates for CCGs working with only one local authority minus the change over time in cervical screening rates for CCGs working with more than one local authority) minus (the change over time in unassisted birth rates for CCGs working with only one local authority minus the change over time in unassisted birth rates for CCGs working with more than one local authority).

The screening rate is defined as the percentage of women aged between 25 and 64 years who had received a cervical screening test in the preceding 5 years. This indicator was derived from annual, practice-level data from the Quality and Outcomes Framework, 2009–10 to 2015–16. The comparison indicator is unassisted births as a percentage of all maternal deliveries. This indicator was produced using operation codes in Hospital Episode Statistics for 2009–10 to 2015–16. We aggregated the spell-level data by general practice and financial year.

The key assumption underpinning the triple-difference estimator is that, conditional on the other variables in the model, the differences in the changes over time in the intervention indicator (cervical screening) between the ‘exposed’ and the ‘control’ areas (in this case, CCGs working with one local authority vs CCGs working with more than one) would have been the same as the differences in the changes over time in the comparison indicator (unassisted births) between the exposed and control areas in the absence of the intervention. This is a more complex version of the ‘parallel trends’ assumption required for the double-difference, or difference-in-differences, estimator. 17

A popular test of this assumption in the double-difference case is that there are parallel trends over time in the outcomes in the intervention and comparison group in the preintervention period. For our triple-difference case, we used an F-test to assess the joint significance of interactions between the year effects and the binary variable representing the combination of exposed area and treated indicator in the preperiod.

We also used the lagged dependent variable (LDV) estimator. This model is estimated only on data in the postintervention period and is a less biased estimator of treatment effects when the assumption of parallel pretrends does not hold. 18 We set up the LDV model to generate the equivalent impact estimate as the triple-difference model. The model included: dummy variables for year; values of the dependent variable in each of the preintervention periods; a dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority; interactions between year and condition dummies; interactions between values of the dependent variable in the preintervention period and the condition dummy and an interaction between the dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority and the condition dummy. The final term is the impact estimate, showing whether cervical screening was differentially affected after the introduction of the reforms for local authorities working with multiple CCGs.

We estimated the regression models in Stata V.14.1 using dummy variable weighted least squares regression with fixed effects for practice-indicator combinations. The ways in which these models are estimated using regression analyses are described formally in the technical online  supplementary appendix . As the dependent variable is a proportion, and constrained to lie between 0 and 1, we used the empirical logit transformation and back-transformed the coefficients and associated 95% CIs using the mean value of the cervical screening rate. 19 We clustered the SEs at the GP practice level. 20 The general form of the STATA command is: areg {depvar} {indepvars} [aw=denom], robust absorb(practicexindicator) cluster(practice).

Supplementary file 1

Qualitative findings.

Interviewees told us that CCGs working with more than one local authority experienced a number of challenges, including: finding sufficient capacity to engage in multiple meetings of the same type with different local authorities; managing additional collaborative relationships; working with organisations experiencing different financial pressures from each other with different approaches to public health spending; and attempting to develop integrated health and social care arrangements with one local authority that did not have unintended and undesirable consequences for plans with another. The following extract illustrates issues relating to difficulties commissioning a single service offer for CCG patients and the additional resources required for a CCG working with multiple local authorities. (Interview data extracts are denoted by square brackets with numerical participant ID, participant’s organisation type, Area (1 or 2) and month and year of the interview.)

We do have two sets of safeguarding arrangements. So I guess at one level, one can say there is a risk of and there are examples of services being subtly different. Equally, you’ve got to service two times the number of these processes, which can be quite labour-intensive. [2778, CCG, Area 1, April 2015]

In our analysis relating directly to issues surrounding the commissioning and provision of cervical screening post-HSCA, we identified two main themes: confusion and uncertainty regarding budgets and responsibilities, and potential impacts on cervical screening rates. Many of the issues discussed below are likely to be exacerbated when the number of interacting commissioning organisations in a local area are increased.

Confusion and uncertainty regarding budgets and responsibilities

Before the HSCA, both cervical screening and sexual health services were commissioned by PCTs. As one screening and immunisation lead outlined, cervical screening tests (sometimes referred to as smear tests) were provided by GP practices, but patients could usually also have them at sexual health clinics [17685, NHSE, Area 2, December 2016]. Whereas pre-HSCA PCTs held the budget for both cervical screening and sexual health services, following the Act these budgets were separated. This meant that the local authority budget and responsibility for sexual health did not extend to cervical screening. One local authority public health consultant reported that, in spite of this, PHE was sending letters to patients explicitly stating that they could choose to attend either their GP practice or their local sexual health clinic for their cervical screening test. This highlights confusion regarding commissioning arrangements and budgetary responsibility:

Public Health England were writing around to people saying …you’re due your smear, you can go to your general practice or you can go to your local sexual health clinic. And we said, but we don’t have the money for them to do that, they can’t come here routinely unless you’re going to pay us for that. Public Health England, the screening people, they have the money to pay for the smears. But in all the moving around of the budgets, the money for smears that were taken outside general practice doesn’t seem to be anywhere. [8384, local authority, Area 1, November 2015]

One participant from NHSE offered a different perspective. He argued that the public health budget of each local authority reflected the levels of cervical screening activity that had taken place in its sexual health clinics pre-HSCA. However, this is not clear because, in the past, the funding was not ‘disaggregated’ [4058, NHSE, Area 1, June 2015]. Therefore, it is not possible to establish what the pre-HSCA sexual health component of the public health budget covered.

…they (local authorities) think they’re not being paid for it (cervical screening). But, actually, in truth, whatever they were doing at the point of transition if they were doing loads of cervical smears they were just doing loads of cervical smears, so they had the money. There wasn’t a problem when they were doing them before, it’s just the money wasn’t disaggregated. However local authorities have been put under significant pressure in their public health teams to reduce their budgets. So these kinds of things are examples where you can say it’s not our responsibility so therefore we’re taking that element out. [4058, NHSE, Area 1, June 2015]

The above quote illustrates a phenomenon reported by a number of participants that local authorities had reprocured their sexual health services and had taken a position that they would not commission their sexual health provider(s) to do routine cervical screening, because it was not their commissioning responsibility. However, as one member of a screening team in Area 2 illustrated, NHSE was also reluctant to explicitly commission sexual health services to provide cervical screening, seemingly because of administrative challenges relating to numerous low-value contracts with providers:

So cervical screening, we could go to every sexual health provider and have a separate contract. The difficulty again becomes around commissioning capacity. So, I think we’ve got [x] local authorities, so we have [x] separate contracts all very low value, it’s about 1000 screens in each, so you’re talking maybe [x] £20 000 contracts or something. So, it’s a very bitty way of doing stuff. So, we could still do it and we could pay for it, but in terms of the amount of paperwork or the amount of outcomes it becomes potentially unmanageable. [17685, PHE/NHSE, Area 2, December 2016]

This participant went on to indicate that he would prefer local authorities to commission cervical screening as part of their sexual health contracts, but acknowledged the political difficulties for local authorities to justify spending money on an area of service that was not formally their responsibility, especially given the context of diminishing local authority budgets:

In a way, wouldn’t it be so much easier if the local authorities just included it as part of their normal service? But their argument would be that’s not our role, and how can we defend to the (elected) councillors that we’re spending money on stuff that we don’t have to, that someone else is meant to be spending money on? And our argument is well, it’s just so much simpler and it’s not a lot of money. That’s the kind of discussion. And it eventually ends up with them withdrawing money and us saying well, we’re not buying it either then. [17685, PHE/NHSE, Area 2, December 2016]

Potential impacts on cervical screening rates

One local authority commissioner suggested that the policy of his local authority was to continue to facilitate opportunistic cervical screening tests at sexual health clinics, but not routine tests, because to provide the latter would have a detrimental impact on other sexual health services that the local authority was now obligated to commission (“if we don’t say no to (routine) smears, we’ll be turning (other) people away, symptomatic patients away, or women needing contraception away. And that’s our duty" [8384, local authority, Area 1, November 2015]). He reported that local CCGs complained about this discontinuation of routine cervical screening at sexual health clinics, because there was insufficient capacity within general practice for CCGs to meet their cervical screening targets, and thus they required sexual health clinics to provide a proportion of cervical screening activity. One screening consultant developed this point by suggesting that some localities would see a substantial reduction in screening activity because of a lack of capacity within primary care:

…in some local authorities where the sexual health service is no longer doing cervical screening (it) will have a small impact but not a huge impact, in other areas, it will have a big impact on coverage, we’ll see activity go down around it, because the workload is just going to come straight back to primary care, and in different areas primary care didn’t realise this was happening, the re-commissioning, hasn’t got the capability and the capacity… [18352, PHE/NHSE, Area 1, January 2017]

Another screening consultant reflected that changes to NHSE ‘footprints’ (ie, the abolition of Area Teams and the new, more regional focus of the organisation) had implications for the provision of cervical screening:

…say we wanted to sort out cervical screening coverage in GP practices, in (name of PCT) you’ve got [ x ] GP practices, bottom 20 per cent you could talk to the [ y ] practices. In my new patch we’ve got (many more than x ) practices. So you have to think in a completely different way. [17685, NHSE, Area 2, December 2016]

Several participants from different localities in both geographical areas pointed to long-standing challenges in ensuring good uptake rates for screening among their diverse local populations. There were concerns that these challenges would be exacerbated by a reduction in choice for women about where they could go for cervical screening tests:

…you should have an integrated sexual health service where predominantly women can go in and get seen in one episode, in one place for all their sexual health needs, be that sexually transmitted infection testing and treatment and contraception. So I think probably in the past people worked very hard to get things like cervical screening into these services so that the needs of those women who perhaps wouldn’t go to their local GP could be met in an environment they felt happy with. My feeling is now… that perhaps the type of women who traditionally would have gone for cervical screening (at their sexual health clinic) might not feel so comfortable in that environment (of the GP practice). So particularly, say, a lady from a South Asian background who goes to a single handed male GP with no practice nurse, that’s the kind of traditional person who might have gone to a family planning clinic for their cervical screening. [9742, local authority, Area 2, January 2016]

The HSCA separated commissioning responsibilities for some types of services, including sexual health. Our study participants told us that this had introduced complexity and confusion surrounding cervical screening commissioning, and they expressed concern that screening rates would decline as a result, with some areas potentially affected more than others due to differences in local contextual conditions. In order to explore this further, we designed a quantitative analysis to test the proposition that CCGs most affected by this increase in complexity would have a greater decline in screening rates. Based on the findings from our interviews that working with more than one local authority acted to increase the complexity associated with the commissioning role, we compared screening rates between those CCGs which relate to a single local authority and those required to work with two or more local authorities.

Quantitative findings

There were 14.1 million women eligible for screening in England in 2016. 21 Cervical screening rates decreased over time and the decline predated the implementation of the HSCA in April 2013. Unassisted delivery rates also declined over time. The relative decline between the first year (2009–10) and the last year (2015–16) for unassisted deliveries (−4.17%) was larger than for cervical screening (−2.70%) ( table 3 ).

Numbers of general practices and mean rates of cervical screening and unassisted deliveries by year and by the number of LAs with which CCGs had to coordinate commissioning

Mean cervical screening and unassisted delivery rates are weighted by the denominators used in the calculation of the rates. These are the eligible populations; the number of women aged between 25 and 64 years or the number of maternal deliveries.

CCG, Clinical Commissioning Group; LA, local authority.

The changes in cervical screening rates over time were similar for practices in CCGs dealing with a single local authority (−2.53%) compared with practices in CCGs working with multiple local authorities (−2.87%). Figure 1 illustrates the trends in rates of cervical screening in the preintervention and postintervention periods for CCGs depending on the number of local authorities they worked with. There is a noticeable and sharp decline in the rates in both groups between 2011–12 and 2012–13.

Uptake (%) of cervical screening pre-HSCA and post-HSCA. HSCA, Health and Social Care Act 2012; LA, local authority.

Comparing the unadjusted averages for the pre-HSCA and post-HSCA years, cervical screening rates decreased by 0.39% more for GP practices located in CCGs working with multiple local authorities compared with practices in CCGs working with a single local authority. Unassisted birth rates decreased by 0.40% less for GP practices in CCGs working with multiple local authorities compared with GP practices in CCGs working with a single local authority. As maternity services were largely unaffected by the HSCA, we assumed that these differential changes captured the unmeasured population influences that confound comparisons of the changes in the two groups of CCGs. Relative to the decreases in unassisted delivery rates, GP practices in CCGs working with multiple local authorities experienced a decrease in cervical screening rates of 0.79% compared with practices in CCGs working with a single local authority ( table 4 ).

Rates of cervical screening and unassisted birth for CCGs working with one and more than one LA, before and after the introduction of the HSCA

Values for pre and post are averages for all years in pre and post periods. The averages are weighted by the denominators used in the calculation of the rates. These are the eligible populations; the number of women aged between 25 and 64 years or the number of maternal deliveries.

CCG, Clinical Commissioning Group; HSCA, Health and Social Care Act 2012; LA, local authority.

The results were qualitatively similar when we estimated the formal triple difference (for all years and 2011–12 onwards only) and lagged dependent variable regression models ( table 5 ). The triple-difference estimates show that there was a differentially larger decline of 0.62% (95% CI −0.941 to −0.297) (model 1) in cervical screening rates for practices located in CCGs working with more than one local authority. The decrease is smaller using the shorter preperiod (0.259%; 95% CI −0.573 to 0.052, model 2).

Triple-difference regression results

Values are regression estimations from weighted least squares models on the empirical logit transformation of the rate including practice condition-specific fixed effects, full interaction of year with condition; and full interaction of year with the dummy for (N of LAs). Weighted by the denominators used to calculate the rates. Robust SEs, clustered by practice.

The triple difference represents (the change over time in cervical screening rates for CCGs working with only one LA minus the change over time in cervical screening rates for CCGs working with more than one LA) minus (the change over time in unassisted birth rates for CCGs working with only one LA minus the change over time in unassisted birth rates for CCGs working with more than one LA).

This model uses an alternative grouping of CCGs based on the number of LAs they work with ([1 or 2] vs [>2]).

LDV also contains values of the dependent variable in each of the pre intervention years. Estimated only on post intervention years.

CCG, Clinical Commissioning Group; LA, local authority; N/A, not available.

The direction of result is robust to the model specification and, although we rejected the assumption of parallel trends for model 1 (all years), we could not reject the assumption for model 2 (2011–12 onwards). We also found a similar result in model 3 using the lagged dependent variable estimator, which yields unbiased estimates when pretrends cannot be assumed to be parallel.

The results are also robust to different groupings of the number of local authorities that CCGs work with. Table 5 includes model estimates comparing CCGs working with one or two local authorities with CCGs working with more than two local authorities. The direction of results is equivalent; and the scale and significance are either equivalent or increased. The same pattern is repeated in terms of tests of parallel trends. We cannot reject the null hypothesis of parallel trends for model 2 and the LDV estimation is preferable to model 1 in which we can reject the null hypothesis of parallel trends.

We conducted a mixed methods study exploring the impact of changes associated with the HSCA in the English NHS on cervical screening rates. We carried out qualitative interviews with senior figures from a variety of relevant organisations in two large, socioeconomically diverse areas of England. Analysis of these interviews suggested that cervical screening commissioning had become more complex, with responsibilities between organisations less certain, as a consequence of the HSCA. Some interviewees predicted there would be a reduction in cervical screening rates in particular areas. These findings prompted the development of an analysis to explore these issues quantitatively via a triple-difference regression analysis of publicly available data on cervical screening activity. To control for unmeasured confounders, we compared cervical screening rates with trends in unassisted birth rates because the commissioning of maternity services was unchanged pre-HSCA and post-HSCA.

Interviewees suggested a number of factors that might contribute to a reduction in cervical screening activity. Sexual health service commissioning responsibility had shifted to local authorities while NHSE was made responsible for commissioning national screening services, including cervical screening. Faced with financial austerity and cuts to their budgets, many local authorities were retendering their sexual health services with sexual health service providers but not including routine cervical screening. NHSE was also seemingly reluctant to commission sexual health clinics to perform cervical screening tests because this would entail a multitude of low-value contracts with numerous providers. This would be administratively laborious and practically difficult given the large size of NHSE’s administrative areas and small numbers of NHSE commissioning staff in each area.

The quantitative analysis was designed to explore whether cervical screening activity had declined in areas most affected by commissioning organisational change. GP practices located in CCGs dealing with multiple local authorities, and therefore most exposed to increased commissioning complexity and potential disruption in services because of the lack of clarity of the roles of different organisations, experienced a larger decrease over time in cervical screening rates compared with practices in CCGs dealing with a single local authority. The opposite pattern was observed for unassisted births, which decreased more over time in the CCGs dealing with a single local authority. The triple-difference analyses confirmed that the effects were statistically significant and robust to different model specifications.

We have demonstrated unintended consequences arising out of a large-scale health system reform. Taken together, our findings suggest that there is an urgent need for clarification as to who holds the budget, and therefore who should be commissioning, cervical screening in the English NHS, and for local agreements to ensure that issues over funding and budgets do not disrupt screening programmes. More broadly, the issues we have identified in this study are of value to policy makers and system leaders in other health systems. The current study suggests that there are particular problems associated with service commissioning where coordination is required between multiple commissioners. This suggests that future commissioning reforms should include assessment of the likely impact on coordination, and a presumption in favour of commissioning all required services for geographical populations where possible. This may also have implications for mixed health systems, in which multiple payers (including public and private insurers as well as out of pocket payments) are responsible for services. In such systems achieving desirable population coverage for services such as screening may require specific coordination efforts.

Potential confounders and study strengths

We took 2009 as our starting point for pre-HSCA cervical screening activity. Two potential confounders to our results were considered. First, the high-profile case of Jade Goody, a reality TV star who was diagnosed with cervical cancer in August 2008 and died in March 2009. The contemporaneous media attention and publicity was linked with a substantial increase in cervical screening rates (around an extra half a million women) during the time between Goody’s diagnosis and death. However, previous impacts of high-profile cases of celebrity cancer diagnoses on population behaviour have tended to be brief and immediate rather than longer-lasting, and, therefore, we are confident that from 2010, rates of cervical screening returned towards underlying trends. 22 Second, the UK’s Human Papillomavirus (HPV) vaccination programme was introduced in 2008 in order to reduce the incidence of cervical cancer. 23 The vaccine is offered to all girls aged 12–13 years, and figures for 2008–14 show high uptake rates of just under 90%. It is likely that this vaccination programme will contribute to a reduction in cervical screening activity in future. However, the first cohort of women in the programme, that is, those aged 12–13 years in 2008, were aged only 21–22 years in 2016–17, hence too young to have been invited for routine cervical screening (which begins at age 25) at the time of the study. We can, therefore, be confident that any changes to cervical screening rates cannot yet be attributed directly to the HPV programme, but any future research into cervical screening rates needs to take this into account.

We considered whether the results were sensitive to the group of CCGs in terms of the number of local authorities they worked with. The direction of results was the same, and the strength and significance was increased, comparing CCGs working with one or two local authorities with those CCGs working with more than two local authorities. We also considered whether the results were sensitive to the choice of comparison indicator (unassisted births) for maternity services. We tested whether the results would hold for another indicator of maternity services: the rate of deliveries by caesarean section. We observed the same direction and significance of results for this indicator as well.

The average age of mothers at delivery is likely to be younger than the average age of women attending for cervical screening. For our analysis, we require that differential changes in maternity indicators between CCGs with simple and CCGs with complex local authority relationships are a good proxy for other factors influencing cervical screening rates. We have confirmed the empirical validity of this assumption by looking for parallel trends in the period before the HSCA, but we can never be entirely sure of its validity.

The findings presented here come from a longitudinal study of major healthcare system reform conducted by a multidisciplinary research team. The nature of this study facilitated the development of the relatively novel, sequential mixed methods approach in which the claims made in qualitative interviews could be tested in a subsequent quantitative analysis. There is a reinforcing effect in this analytical approach, which provides a strong cumulative indication that in areas of the country where complexity and coordination issues linked to the HSCA were more likely to occur there was an associated reduction in cervical screening rates.

Supplementary Material

Acknowledgments.

The authors would like to thank the research participants for their involvement, and acknowledge the valuable advice of the Project Advisory Group.

Contributors: KC designed the study with input from MS, NM, PA, AC. JH, AH, LW-G gathered and analysed the qualitative data. TM and MS designed the quantitative evaluation and conducted this analysis. JH drafted the manuscript to which all authors made substantial contributions. All authors approved the final version and agree to be accountable for all aspects of the analysis.

Funding: The report is based on independent research commissioned and funded by the NIHR Policy Research Programme (‘Understanding the new commissioning system in England: contexts, mechanisms and outcomes’, PR-R6-1113-25001).

Disclaimer: The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, arm’s-length bodies or other government departments.

Competing interests: None declared.

Ethics approval: Ethical approval was granted by one of The University of Manchester Research Ethics Committees (application 15085) in March 2015. Participants were provided written information about the study, provided written consent or gave consent verbally at the beginning of telephone interviews.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: No additional data are available.

Patient consent for publication: Not required.

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Please note you do not have access to teaching notes, the impact of the health and social care act, 2012 on the health and wellbeing of rough sleepers.

Journal of Integrated Care

ISSN : 1476-9018

Article publication date: 17 October 2016

The purpose of this paper is to explore the impact of the Health and Social Care Act, 2012 on London’s rough sleepers as seen from the perspective of one former homeless service user (currently working as a support worker in a day centre providing outreach and “drop in” facilities for people who are street homeless and other vulnerable adults including female sex workers). The discussion centres on some of the unintended impacts of changes to healthcare commissioning; the new arrangements for patient, public representation; and the enhanced role of local councils.

Design/methodology/approach

This paper is grounded in front line practitioner reflection/opinion and draws on practical experience and observation at Spires, as well as research and government papers published by other service providers. The aspirations of the Health and Social Care Act, 2012 are set out before its practical application are examined from the rough sleeper’s dimension.

Putting clinicians and GPs centre stage in the commissioning and purchasing of healthcare may have some benefits for individual patient choice, but it can also dilute patient public involvement in health and social care with negative effects for vulnerable and excluded groups, including rough sleepers. The terms of reference ascribed to Local Healthwatch Organisations, the official representatives of the people, are narrower than previously and limit their ability to influence official policy. The Act centralises control whilst devolving operational responsibility, especially for public health provision on which rough sleepers often rely. It is suggested that local voluntary organisations and specialist “inclusion” health groups are increasingly being expected to take over responsibility for delivering health and social care and that mainstream collaboration is much reduced rather than enhanced by this fragmentation.

Research limitations/implications

This review is based on the opinion of an “expert by experience” which may not be representative.

Originality/value

This is one of few papers which present a front line service user/practitioner perspective on the impact of clinical commissioning on services for marginalised groups.

• Homelessness
• Third sector
• Patient choice
• Clinical Commissioning Groups (CCGs)
• Community and Voluntary Organizations (CVOs)
• Rough sleepers

Acknowledgements

Thanks to Dr Michelle Cornes, Senior Research Fellow, Social Care Workforce Research Unit, King’s College London for her support with earlier drafts of this paper. The views expressed are those of the author and are not necessarily shared by Spires, whose management accept no responsibility for the sentiments contained herein.

Fuller, J.S. (2016), "The impact of the Health and Social Care Act, 2012 on the health and wellbeing of rough sleepers", Journal of Integrated Care , Vol. 24 No. 5/6, pp. 249-259. https://doi.org/10.1108/JICA-05-2016-0018

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Copyright © 2016, Emerald Group Publishing Limited

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• Volume 9, Issue 4
• Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening
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• Jonathan Hammond 1 , 2 , 3 ,
• Thomas Mason 1 , 2 , 3 , 4 ,
• Matt Sutton 1 , 2 , 3 ,
• Alex Hall 2 , 5 ,
• Nicholas Mays 6 ,
• Anna Coleman 1 , 2 , 3 ,
• Pauline Allen 7 ,
• Lynsey Warwick-Giles 1 , 2 , 3 ,
• Kath Checkland 1 , 2 , 3
• 1 Division of Population Health, Health Services Research, and Primary Care , University of Manchester , Manchester , UK
• 2 School of Health Sciences , University of Manchester , Manchester , UK
• 3 Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
• 4 Manchester Centre for Health Economics , University of Manchester , Manchester , UK
• 5 Division of Nursing, Midwifery and Social Work , University of Manchester , Manchester , UK
• 6 Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
• 7 Health Services Research Unit , London , UK
• Correspondence to Dr Jonathan Hammond; jonathan.hammond{at}manchester.ac.uk

Objectives Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms.

Methods Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25–64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome—unassisted birth rates—largely unaffected by HSCA changes.

Results Interviewees identified that cervical screening commissioning and provision was more complex and ‘fragmented’, with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups.

Conclusions Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.

• health policy
• health system reform
• mixed methods
• commissioning

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2018-024156

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Strengths and limitations of this study

Few studies have investigated in detail the impacts of large-scale health system change.

This study combines detailed qualitative data exploring impacts on the system with quantitative exploration of important outcomes, supporting causal inference.

Based on qualitative findings, we developed a quantitative measure for assessing the extent of disruption to the English NHS commissioning system as a result of the 2012 Health and Social Care Act.

We found that cervical screening rates decreased more post-Act in areas that had experienced higher levels of disruption.

Introduction  

Structural reorganisations of publicly financed healthcare systems, driven by central government or other state agencies, are frequently employed with the objective of improving healthcare delivery, and thus population health outcomes, while reducing or containing costs. 1 However, such endeavours can be disruptive and expensive. 2 It is important to understand what possible impacts these reorganisations have in order to understand their value. 3

In the English National Health Service (NHS), attempts to evaluate the impact of reorganisations have typically used operational indicators (eg, bed availability, number of staff) and measures of clinical activity because their improvement was the stated goal of government policy (eg, The NHS Plan 4 ). Other studies have attempted to assess the impacts of reforms by measuring their effects on prices, quality and quantity of provision. 5 Most studies have relied on quantitative analysis of measures that were explicitly targeted by policy reforms. There is a need for approaches which combine qualitative and quantitative methods to generate a deeper understanding of the impacts of structural reorganisation. 6

The most recent structural reorganisation of the English NHS, the Health and Social Care Act 7 (hereafter ‘HSCA’ or ‘the Act’), was introduced in April 2013 and included wide-ranging changes to the health services commissioning system. We explore whether changes to the commissioning of cervical screening services resulting from the Act affected uptake. This analysis uses a relatively novel mixed methods approach. An initial ‘bottom-up’ qualitative analysis allowed us to identify problematic issues associated with the HSCA for those working locally in the health service commissioning system. This process highlighted the disruption to established commissioning arrangements and cervical screening as a clinical activity, which may be specifically affected by this disruption. We then developed a quantitative investigation to explore this more fully. Together these analyses allow us to infer causation.

The HSCA and changes to cervical screening commissioning

The HSCA is regarded as one of the most wide-ranging legislative reforms in the history of the English NHS. 8  Primary Care Trusts (PCTs), 152 organisations previously responsible for the commissioning of primary, community and secondary health services from providers on behalf of local populations, were abolished. Their commissioning functions were split between three groups of organisations: 211 (now 195) newly created Clinical Commissioning Groups (CCGs), membership organisations constituted by general practitioner (GP) (family doctor) practices, given responsibility for commissioning services for their local populations; NHS England (NHSE), a new arm’s-length governmental body with responsibility for authorising and assessing CCGs and commissioning some services at a national level; and top-tier and single-tier elected local authorities, which took responsibility for the majority of public health services for the first time since 1974. In addition, Public Health England (PHE) was created as an executive agency of the Department of Health, to unify the diverse public health profession and provide expert support for local public health services.

In some service areas, the transfer of commissioning responsibilities was relatively straightforward (eg, the commissioning of routine orthopaedic surgery was passed from PCTs to CCGs with minimal alteration to the bundle of services involved). In other service areas, the transfers were much more complex, particularly the commissioning of national screening programmes and sexual health services, as a result of changes to public health commissioning. Pre-HSCA, national screening programmes and sexual health services were both commissioned by PCTs. Cervical screening was largely provided by GP practices, which received additional funding linked to levels of activity, 9 but some women opted to have their cervical smears in PCT-commissioned sexual health clinics. Post-HSCA, responsibility for public health services, including most sexual health services, was transferred to local authorities. The underlying programme theory (ie, the explicit expectation about how the policy would work 10 ) was that local authorities would be better placed to address the wider determinants of health and well-being than the NHS because they could link public health services with their existing responsibilities, such as for transport and housing. 11 NHSE took responsibility for commissioning national screening programmes. 8 NHSE’s regional teams are responsible for commissioning screening programmes, supported by PHE staff ‘embedded’ within NHSE’s screening and immunisation teams. 12 There was no identifiable underlying programme theory for this specific change to screening programme commissioning. However, it is notable that, in contrast to the emphasis placed on localism associated with the creation of CCGs and with the transfer of public health to local authorities, screening commissioning became more centralised as a consequence of the HSCA.

Table 1 shows the organisations with responsibilities of relevance to the commissioning of sexual health, including cervical cancer screening services, pre-HSCA and post-HSCA. It illustrates how responsibility for such services, previously commissioned by PCTs, was split between different agencies. This increased complexity and fragmentation of responsibilities had the potential to disrupt service commissioning. 13

• View inline

Organisations of significance to the commissioning of cervical screening pre-HSCA and post-HSCA

This analysis comes from a study designed to foster emergent interplay between qualitative and quantitative data analysis. 14 15 The focus on cervical screening was not established at the project design stage but driven by the initial qualitative interview findings related to sexual health commissioning arrangements and screening activity post-HSCA. These findings prompted us to consider a quantitative exploration of predictions made by interviewees relating to potential changes in cervical screening activity.

Study context and design

This analysis forms part of a longitudinal project, with data collected between January 2015 and December 2017, into the effect of the HSCA on the commissioning system in England. We combined a qualitative and quantitative exploration of the commissioning of services in two large, socioeconomically diverse metropolitan areas of England with a national level quantitative study of commissioning outcomes. We used a sequential mixed methods approach in which initial qualitative data collection and analysis were used to shape an ensuing quantitative analysis using routinely available data. We therefore present the qualitative and quantitative methods and findings in the order undertaken, and integrate them in the ’Discussion' section.

Patient and public involvement

Our interest in exploring the impact of systemic commissioning change on cervical screening rates was driven initially by concerns expressed by interviewees about potentially negative consequences for patients relating to new arrangements. Patients were not directly involved in the design of, or recruitment to, the overarching project, but an advisory group including a patient representative met regularly throughout the project and played an important role in supporting its development. We presented our initial qualitative findings relating to cervical screening, and early ideas for developing a mixed methods investigation, to our advisory group and were encouraged by our patient representative to pursue this. The results of the broader project were disseminated to participants, and the advisory group, in the form of a series of short reports focusing on specific areas of commissioning and the final report.

Qualitative component

Setting, participants, sampling and data collection.

The qualitative component took place between March 2015 and August 2017, focussing on two metropolitan ‘health economies’ covering a geographical population and a group of commissioning organisations and providers with close operational links. Across both areas, we conducted 143 interviews (each typically an hour in length), 93 of which related to sexual health commissioning, with clinical and non-clinical commissioners, managers, clinicians and senior administrative staff from CCGs, local authorities, service providers and third sector organisations. Organisations and participants were sampled purposively for variation in type and role. We identified participants through organisational websites, personal contacts and through ‘snowballing’ in which we asked participants to recommend other potential participants. Additionally, 8 hours of meetings of an interorganisational sexual health coordinating group involving sexual health commissioners and providers were observed in one of the areas.

Interviews focused on the commissioning system pre-HSCA and post-HSCA, exploring continuities and changes to personal and organisational roles, key issues and challenges, accountability and performance management, interorganisational relationships and communication and commissioning decision-making. Interviews took place either in person (usually in participants’ offices) or over the telephone. All interviews were audio-recorded and all interviewees were provided with written information about the study before consenting to participate.

Data analysis

Audio recordings of interviews were transcribed verbatim, and observational notes from meetings were produced contemporaneously. Transcripts and observational notes were imported into NVivo V.10 software and analysed thematically by JH and AH. 16 This involved repeated readings of transcripts to become sufficiently familiar with their contents, identifying initial codes and coding chunks of data, searching for themes and then iteratively defining and reconstituting themes. Our findings (see below) contained some predictions made by participants regarding changes in cervical screening activity as a consequence of the Act. This prompted us to explore these predictions in a quantitative analysis, which we now describe.

Quantitative component

Interviewees identified that the HSCA had introduced confusion over responsibility for the commissioning of cervical screening services, and had increased variability of provision. They hypothesised that cervical screening rates might be reduced by the new commissioning arrangements; this prompted discussions among the research team and advisory group about developing a way of testing these predictions quantitatively as far as routine data would permit. As the Act had been implemented in all areas simultaneously, removing the scope for a quasi-experimental approach, we sought to identify a measure of variability in the extent to which the Act would have been expected to make commissioning more difficult in each area. One of the features of the post-HSCA system was that some, but not all, CCGs were established which crossed local authority boundaries. Some CCGs related to as many as three separate local authorities. Local authorities were now directly involved in sexual health services commissioning. Findings revealed that CCGs experienced extra challenges when they had to engage with more than one local authority. This suggested that the burden of additional interorganisational coordination might have consequences for commissioning.

As each local authority developed its own approach to cervical screening in its local sexual health clinics, we explored the possibility that GP practices located in CCGs which had to work with more than one local authority might experience lower screening rates compared with practices located in CCGs which had only to deal with one local authority. We compare the demographic characteristics of these two groups in table 2 . The 89 CCGs dealing with more than one local authority had a slightly older population profile than the 119 CCGs which dealt with only one local authority but were otherwise highly comparable.

Clinical Commissioning Group (CCG) demographic characteristics depending on the number of local authorities that the CCG needs to work with

Because cervical screening rates may be influenced by other factors that we cannot observe and may change over time in different ways between the two groups of CCGs, we also compared screening rates with an outcome that was unlikely to have been affected by the introduction of the HSCA. We used unassisted births (ie, uncomplicated deliveries which did not require any intervention) as a percentage of all maternal deliveries, since the commissioning of maternity services was largely unchanged by the Act.

We applied a triple-difference approach. The triple difference represents (the change over time in cervical screening rates for CCGs working with only one local authority minus the change over time in cervical screening rates for CCGs working with more than one local authority) minus (the change over time in unassisted birth rates for CCGs working with only one local authority minus the change over time in unassisted birth rates for CCGs working with more than one local authority).

The screening rate is defined as the percentage of women aged between 25 and 64 years who had received a cervical screening test in the preceding 5 years. This indicator was derived from annual, practice-level data from the Quality and Outcomes Framework, 2009–10 to 2015–16. The comparison indicator is unassisted births as a percentage of all maternal deliveries. This indicator was produced using operation codes in Hospital Episode Statistics for 2009–10 to 2015–16. We aggregated the spell-level data by general practice and financial year.

The key assumption underpinning the triple-difference estimator is that, conditional on the other variables in the model, the differences in the changes over time in the intervention indicator (cervical screening) between the ‘exposed’ and the ‘control’ areas (in this case, CCGs working with one local authority vs CCGs working with more than one) would have been the same as the differences in the changes over time in the comparison indicator (unassisted births) between the exposed and control areas in the absence of the intervention. This is a more complex version of the ‘parallel trends’ assumption required for the double-difference, or difference-in-differences, estimator. 17

A popular test of this assumption in the double-difference case is that there are parallel trends over time in the outcomes in the intervention and comparison group in the preintervention period. For our triple-difference case, we used an F-test to assess the joint significance of interactions between the year effects and the binary variable representing the combination of exposed area and treated indicator in the preperiod.

We also used the lagged dependent variable (LDV) estimator. This model is estimated only on data in the postintervention period and is a less biased estimator of treatment effects when the assumption of parallel pretrends does not hold. 18 We set up the LDV model to generate the equivalent impact estimate as the triple-difference model. The model included: dummy variables for year; values of the dependent variable in each of the preintervention periods; a dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority; interactions between year and condition dummies; interactions between values of the dependent variable in the preintervention period and the condition dummy and an interaction between the dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority and the condition dummy. The final term is the impact estimate, showing whether cervical screening was differentially affected after the introduction of the reforms for local authorities working with multiple CCGs.

We estimated the regression models in Stata V.14.1 using dummy variable weighted least squares regression with fixed effects for practice-indicator combinations. The ways in which these models are estimated using regression analyses are described formally in the technical online  supplementary appendix . As the dependent variable is a proportion, and constrained to lie between 0 and 1, we used the empirical logit transformation and back-transformed the coefficients and associated 95% CIs using the mean value of the cervical screening rate. 19 We clustered the SEs at the GP practice level. 20 The general form of the STATA command is: areg {depvar} {indepvars} [aw=denom], robust absorb(practicexindicator) cluster(practice).

Supplementary file 1

Qualitative findings.

Interviewees told us that CCGs working with more than one local authority experienced a number of challenges, including: finding sufficient capacity to engage in multiple meetings of the same type with different local authorities; managing additional collaborative relationships; working with organisations experiencing different financial pressures from each other with different approaches to public health spending; and attempting to develop integrated health and social care arrangements with one local authority that did not have unintended and undesirable consequences for plans with another. The following extract illustrates issues relating to difficulties commissioning a single service offer for CCG patients and the additional resources required for a CCG working with multiple local authorities. (Interview data extracts are denoted by square brackets with numerical participant ID, participant’s organisation type, Area (1 or 2) and month and year of the interview.)

We do have two sets of safeguarding arrangements. So I guess at one level, one can say there is a risk of and there are examples of services being subtly different. Equally, you’ve got to service two times the number of these processes, which can be quite labour-intensive. [2778, CCG, Area 1, April 2015]

In our analysis relating directly to issues surrounding the commissioning and provision of cervical screening post-HSCA, we identified two main themes: confusion and uncertainty regarding budgets and responsibilities, and potential impacts on cervical screening rates. Many of the issues discussed below are likely to be exacerbated when the number of interacting commissioning organisations in a local area are increased.

Confusion and uncertainty regarding budgets and responsibilities

Before the HSCA, both cervical screening and sexual health services were commissioned by PCTs. As one screening and immunisation lead outlined, cervical screening tests (sometimes referred to as smear tests) were provided by GP practices, but patients could usually also have them at sexual health clinics [17685, NHSE, Area 2, December 2016]. Whereas pre-HSCA PCTs held the budget for both cervical screening and sexual health services, following the Act these budgets were separated. This meant that the local authority budget and responsibility for sexual health did not extend to cervical screening. One local authority public health consultant reported that, in spite of this, PHE was sending letters to patients explicitly stating that they could choose to attend either their GP practice or their local sexual health clinic for their cervical screening test. This highlights confusion regarding commissioning arrangements and budgetary responsibility:

Public Health England were writing around to people saying …you’re due your smear, you can go to your general practice or you can go to your local sexual health clinic. And we said, but we don’t have the money for them to do that, they can’t come here routinely unless you’re going to pay us for that. Public Health England, the screening people, they have the money to pay for the smears. But in all the moving around of the budgets, the money for smears that were taken outside general practice doesn’t seem to be anywhere. [8384, local authority, Area 1, November 2015]

One participant from NHSE offered a different perspective. He argued that the public health budget of each local authority reflected the levels of cervical screening activity that had taken place in its sexual health clinics pre-HSCA. However, this is not clear because, in the past, the funding was not ‘disaggregated’ [4058, NHSE, Area 1, June 2015]. Therefore, it is not possible to establish what the pre-HSCA sexual health component of the public health budget covered.

…they (local authorities) think they’re not being paid for it (cervical screening). But, actually, in truth, whatever they were doing at the point of transition if they were doing loads of cervical smears they were just doing loads of cervical smears, so they had the money. There wasn’t a problem when they were doing them before, it’s just the money wasn’t disaggregated. However local authorities have been put under significant pressure in their public health teams to reduce their budgets. So these kinds of things are examples where you can say it’s not our responsibility so therefore we’re taking that element out. [4058, NHSE, Area 1, June 2015]

The above quote illustrates a phenomenon reported by a number of participants that local authorities had reprocured their sexual health services and had taken a position that they would not commission their sexual health provider(s) to do routine cervical screening, because it was not their commissioning responsibility. However, as one member of a screening team in Area 2 illustrated, NHSE was also reluctant to explicitly commission sexual health services to provide cervical screening, seemingly because of administrative challenges relating to numerous low-value contracts with providers:

So cervical screening, we could go to every sexual health provider and have a separate contract. The difficulty again becomes around commissioning capacity. So, I think we’ve got [x] local authorities, so we have [x] separate contracts all very low value, it’s about 1000 screens in each, so you’re talking maybe [x] £20 000 contracts or something. So, it’s a very bitty way of doing stuff. So, we could still do it and we could pay for it, but in terms of the amount of paperwork or the amount of outcomes it becomes potentially unmanageable. [17685, PHE/NHSE, Area 2, December 2016]

This participant went on to indicate that he would prefer local authorities to commission cervical screening as part of their sexual health contracts, but acknowledged the political difficulties for local authorities to justify spending money on an area of service that was not formally their responsibility, especially given the context of diminishing local authority budgets:

In a way, wouldn’t it be so much easier if the local authorities just included it as part of their normal service? But their argument would be that’s not our role, and how can we defend to the (elected) councillors that we’re spending money on stuff that we don’t have to, that someone else is meant to be spending money on? And our argument is well, it’s just so much simpler and it’s not a lot of money. That’s the kind of discussion. And it eventually ends up with them withdrawing money and us saying well, we’re not buying it either then. [17685, PHE/NHSE, Area 2, December 2016]

Potential impacts on cervical screening rates

One local authority commissioner suggested that the policy of his local authority was to continue to facilitate opportunistic cervical screening tests at sexual health clinics, but not routine tests, because to provide the latter would have a detrimental impact on other sexual health services that the local authority was now obligated to commission (“if we don’t say no to (routine) smears, we’ll be turning (other) people away, symptomatic patients away, or women needing contraception away. And that’s our duty" [8384, local authority, Area 1, November 2015]). He reported that local CCGs complained about this discontinuation of routine cervical screening at sexual health clinics, because there was insufficient capacity within general practice for CCGs to meet their cervical screening targets, and thus they required sexual health clinics to provide a proportion of cervical screening activity. One screening consultant developed this point by suggesting that some localities would see a substantial reduction in screening activity because of a lack of capacity within primary care:

…in some local authorities where the sexual health service is no longer doing cervical screening (it) will have a small impact but not a huge impact, in other areas, it will have a big impact on coverage, we’ll see activity go down around it, because the workload is just going to come straight back to primary care, and in different areas primary care didn’t realise this was happening, the re-commissioning, hasn’t got the capability and the capacity… [18352, PHE/NHSE, Area 1, January 2017]

Another screening consultant reflected that changes to NHSE ‘footprints’ (ie, the abolition of Area Teams and the new, more regional focus of the organisation) had implications for the provision of cervical screening:

…say we wanted to sort out cervical screening coverage in GP practices, in (name of PCT) you’ve got [ x ] GP practices, bottom 20 per cent you could talk to the [ y ] practices. In my new patch we’ve got (many more than x ) practices. So you have to think in a completely different way. [17685, NHSE, Area 2, December 2016]

Several participants from different localities in both geographical areas pointed to long-standing challenges in ensuring good uptake rates for screening among their diverse local populations. There were concerns that these challenges would be exacerbated by a reduction in choice for women about where they could go for cervical screening tests:

…you should have an integrated sexual health service where predominantly women can go in and get seen in one episode, in one place for all their sexual health needs, be that sexually transmitted infection testing and treatment and contraception. So I think probably in the past people worked very hard to get things like cervical screening into these services so that the needs of those women who perhaps wouldn’t go to their local GP could be met in an environment they felt happy with. My feeling is now… that perhaps the type of women who traditionally would have gone for cervical screening (at their sexual health clinic) might not feel so comfortable in that environment (of the GP practice). So particularly, say, a lady from a South Asian background who goes to a single handed male GP with no practice nurse, that’s the kind of traditional person who might have gone to a family planning clinic for their cervical screening. [9742, local authority, Area 2, January 2016]

The HSCA separated commissioning responsibilities for some types of services, including sexual health. Our study participants told us that this had introduced complexity and confusion surrounding cervical screening commissioning, and they expressed concern that screening rates would decline as a result, with some areas potentially affected more than others due to differences in local contextual conditions. In order to explore this further, we designed a quantitative analysis to test the proposition that CCGs most affected by this increase in complexity would have a greater decline in screening rates. Based on the findings from our interviews that working with more than one local authority acted to increase the complexity associated with the commissioning role, we compared screening rates between those CCGs which relate to a single local authority and those required to work with two or more local authorities.

Quantitative findings

There were 14.1 million women eligible for screening in England in 2016. 21 Cervical screening rates decreased over time and the decline predated the implementation of the HSCA in April 2013. Unassisted delivery rates also declined over time. The relative decline between the first year (2009–10) and the last year (2015–16) for unassisted deliveries (−4.17%) was larger than for cervical screening (−2.70%) ( table 3 ).

Numbers of general practices and mean rates of cervical screening and unassisted deliveries by year and by the number of LAs with which CCGs had to coordinate commissioning

The changes in cervical screening rates over time were similar for practices in CCGs dealing with a single local authority (−2.53%) compared with practices in CCGs working with multiple local authorities (−2.87%). Figure 1 illustrates the trends in rates of cervical screening in the preintervention and postintervention periods for CCGs depending on the number of local authorities they worked with. There is a noticeable and sharp decline in the rates in both groups between 2011–12 and 2012–13.

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Uptake (%) of cervical screening pre-HSCA and post-HSCA. HSCA, Health and Social Care Act 2012; LA, local authority.

Comparing the unadjusted averages for the pre-HSCA and post-HSCA years, cervical screening rates decreased by 0.39% more for GP practices located in CCGs working with multiple local authorities compared with practices in CCGs working with a single local authority. Unassisted birth rates decreased by 0.40% less for GP practices in CCGs working with multiple local authorities compared with GP practices in CCGs working with a single local authority. As maternity services were largely unaffected by the HSCA, we assumed that these differential changes captured the unmeasured population influences that confound comparisons of the changes in the two groups of CCGs. Relative to the decreases in unassisted delivery rates, GP practices in CCGs working with multiple local authorities experienced a decrease in cervical screening rates of 0.79% compared with practices in CCGs working with a single local authority ( table 4 ).

Rates of cervical screening and unassisted birth for CCGs working with one and more than one LA, before and after the introduction of the HSCA

The results were qualitatively similar when we estimated the formal triple difference (for all years and 2011–12 onwards only) and lagged dependent variable regression models ( table 5 ). The triple-difference estimates show that there was a differentially larger decline of 0.62% (95% CI −0.941 to −0.297) (model 1) in cervical screening rates for practices located in CCGs working with more than one local authority. The decrease is smaller using the shorter preperiod (0.259%; 95% CI −0.573 to 0.052, model 2).

Triple-difference regression results

The direction of result is robust to the model specification and, although we rejected the assumption of parallel trends for model 1 (all years), we could not reject the assumption for model 2 (2011–12 onwards). We also found a similar result in model 3 using the lagged dependent variable estimator, which yields unbiased estimates when pretrends cannot be assumed to be parallel.

The results are also robust to different groupings of the number of local authorities that CCGs work with. Table 5 includes model estimates comparing CCGs working with one or two local authorities with CCGs working with more than two local authorities. The direction of results is equivalent; and the scale and significance are either equivalent or increased. The same pattern is repeated in terms of tests of parallel trends. We cannot reject the null hypothesis of parallel trends for model 2 and the LDV estimation is preferable to model 1 in which we can reject the null hypothesis of parallel trends.

We conducted a mixed methods study exploring the impact of changes associated with the HSCA in the English NHS on cervical screening rates. We carried out qualitative interviews with senior figures from a variety of relevant organisations in two large, socioeconomically diverse areas of England. Analysis of these interviews suggested that cervical screening commissioning had become more complex, with responsibilities between organisations less certain, as a consequence of the HSCA. Some interviewees predicted there would be a reduction in cervical screening rates in particular areas. These findings prompted the development of an analysis to explore these issues quantitatively via a triple-difference regression analysis of publicly available data on cervical screening activity. To control for unmeasured confounders, we compared cervical screening rates with trends in unassisted birth rates because the commissioning of maternity services was unchanged pre-HSCA and post-HSCA.

Interviewees suggested a number of factors that might contribute to a reduction in cervical screening activity. Sexual health service commissioning responsibility had shifted to local authorities while NHSE was made responsible for commissioning national screening services, including cervical screening. Faced with financial austerity and cuts to their budgets, many local authorities were retendering their sexual health services with sexual health service providers but not including routine cervical screening. NHSE was also seemingly reluctant to commission sexual health clinics to perform cervical screening tests because this would entail a multitude of low-value contracts with numerous providers. This would be administratively laborious and practically difficult given the large size of NHSE’s administrative areas and small numbers of NHSE commissioning staff in each area.

The quantitative analysis was designed to explore whether cervical screening activity had declined in areas most affected by commissioning organisational change. GP practices located in CCGs dealing with multiple local authorities, and therefore most exposed to increased commissioning complexity and potential disruption in services because of the lack of clarity of the roles of different organisations, experienced a larger decrease over time in cervical screening rates compared with practices in CCGs dealing with a single local authority. The opposite pattern was observed for unassisted births, which decreased more over time in the CCGs dealing with a single local authority. The triple-difference analyses confirmed that the effects were statistically significant and robust to different model specifications.

We have demonstrated unintended consequences arising out of a large-scale health system reform. Taken together, our findings suggest that there is an urgent need for clarification as to who holds the budget, and therefore who should be commissioning, cervical screening in the English NHS, and for local agreements to ensure that issues over funding and budgets do not disrupt screening programmes. More broadly, the issues we have identified in this study are of value to policy makers and system leaders in other health systems. The current study suggests that there are particular problems associated with service commissioning where coordination is required between multiple commissioners. This suggests that future commissioning reforms should include assessment of the likely impact on coordination, and a presumption in favour of commissioning all required services for geographical populations where possible. This may also have implications for mixed health systems, in which multiple payers (including public and private insurers as well as out of pocket payments) are responsible for services. In such systems achieving desirable population coverage for services such as screening may require specific coordination efforts.

Potential confounders and study strengths

We took 2009 as our starting point for pre-HSCA cervical screening activity. Two potential confounders to our results were considered. First, the high-profile case of Jade Goody, a reality TV star who was diagnosed with cervical cancer in August 2008 and died in March 2009. The contemporaneous media attention and publicity was linked with a substantial increase in cervical screening rates (around an extra half a million women) during the time between Goody’s diagnosis and death. However, previous impacts of high-profile cases of celebrity cancer diagnoses on population behaviour have tended to be brief and immediate rather than longer-lasting, and, therefore, we are confident that from 2010, rates of cervical screening returned towards underlying trends. 22 Second, the UK’s Human Papillomavirus (HPV) vaccination programme was introduced in 2008 in order to reduce the incidence of cervical cancer. 23 The vaccine is offered to all girls aged 12–13 years, and figures for 2008–14 show high uptake rates of just under 90%. It is likely that this vaccination programme will contribute to a reduction in cervical screening activity in future. However, the first cohort of women in the programme, that is, those aged 12–13 years in 2008, were aged only 21–22 years in 2016–17, hence too young to have been invited for routine cervical screening (which begins at age 25) at the time of the study. We can, therefore, be confident that any changes to cervical screening rates cannot yet be attributed directly to the HPV programme, but any future research into cervical screening rates needs to take this into account.

We considered whether the results were sensitive to the group of CCGs in terms of the number of local authorities they worked with. The direction of results was the same, and the strength and significance was increased, comparing CCGs working with one or two local authorities with those CCGs working with more than two local authorities. We also considered whether the results were sensitive to the choice of comparison indicator (unassisted births) for maternity services. We tested whether the results would hold for another indicator of maternity services: the rate of deliveries by caesarean section. We observed the same direction and significance of results for this indicator as well.

The average age of mothers at delivery is likely to be younger than the average age of women attending for cervical screening. For our analysis, we require that differential changes in maternity indicators between CCGs with simple and CCGs with complex local authority relationships are a good proxy for other factors influencing cervical screening rates. We have confirmed the empirical validity of this assumption by looking for parallel trends in the period before the HSCA, but we can never be entirely sure of its validity.

The findings presented here come from a longitudinal study of major healthcare system reform conducted by a multidisciplinary research team. The nature of this study facilitated the development of the relatively novel, sequential mixed methods approach in which the claims made in qualitative interviews could be tested in a subsequent quantitative analysis. There is a reinforcing effect in this analytical approach, which provides a strong cumulative indication that in areas of the country where complexity and coordination issues linked to the HSCA were more likely to occur there was an associated reduction in cervical screening rates.

Acknowledgments

The authors would like to thank the research participants for their involvement, and acknowledge the valuable advice of the Project Advisory Group.

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Contributors KC designed the study with input from MS, NM, PA, AC. JH, AH, LW-G gathered and analysed the qualitative data. TM and MS designed the quantitative evaluation and conducted this analysis. JH drafted the manuscript to which all authors made substantial contributions. All authors approved the final version and agree to be accountable for all aspects of the analysis.

Funding The report is based on independent research commissioned and funded by the NIHR Policy Research Programme (‘Understanding the new commissioning system in England: contexts, mechanisms and outcomes’, PR-R6-1113-25001).

Disclaimer The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, arm’s-length bodies or other government departments.

Competing interests None declared.

Ethics approval Ethical approval was granted by one of The University of Manchester Research Ethics Committees (application 15085) in March 2015. Participants were provided written information about the study, provided written consent or gave consent verbally at the beginning of telephone interviews.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Patient consent for publication Not required.

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1 Secretary of State’s duty to promote comprehensive health service

For section 1 of the National Health Service Act 2006 (Secretary of State’s duty to promote health service) substitute—

“ 1 Secretary of State’s duty to promote comprehensive health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of physical and mental illness.

(2) For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.

(3) The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.

(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed. ”

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