Involving clinicians in commissioning : a case study of policy and process
This thesis examines the issue of clinical involvement in the commissioning process within the NUS internal market. It is based on an applied research project undertaken across the purchaser provider divide in one NHS region, during the 1994- 95 annual commissioning cycle. Six District Health Authorities and thirty NUS Trusts in South East Thames took part in the research, which was commissioned by the South East Commissioning Development Network. The purpose of the research was to support the development of the NHS commissioning function across the region. Specific research objectives included assessing the levels of clinical involvement in commissioning at a local level and exploring how the provider clinicians experienced the commissioning and contracting process. The reasons why health authority Chief Executives and Directors of Public Health wished to address this issue were also explored. The research used both qualitative and quantitative approaches to data-collection and analysis. Indepth, fact-to-face interviews with 10 health authority Chief Executives and Directors of Public Health were followed by a postal survey of 325 clinical directors and similar lead clinicians. The postal survey achieved a 75% response rate. Interviews with health authority Chief Executives and Directors of Public Health found overwhelming support for involving local clinicians in the commissioning process, but a wide diversity in the reasons for this. However, on analysis of the data,a number of common themes emerged. These included the need to access clinical advice, to influence clincial behaviour, to ensure contracts are deliverable and to achieve shared ownership of change. Interviews also highlighted the complexity of the commissioning process, the lack of clarity over the purpose of commissioning, and the shortage of appropriates kills within commissioning authorities. These issues were being made more difficult by a fragmentation of relationships resulting from the introduction of the internal market, and constant organisational changes. The survey of provider clinicians revealed that less than a quarter of respondents had frequent contact with their main commissioners, and only one third felt they had a shared vision for the future of their services. Clinicians were particularly concerned that their commissioners did not understand what they were purchasing, especially in terms of clinical issues, patient need and resource constraints. Where respondents had been involved, it was mostly at the contracting stage of the annual commissioning cycle, and most felt this was inadequate. They felt their input into more strategic areas, such as agreeing service changes and developments, were more important than contract setting, negotiating and monitoring. Clinicians had mixed feelings about the process, with those who reported more frequent direct contact with their main commissioners appearing more positive. Overall, there was strong support for increasing levels of clinical involvement in commissioning, and evidence of considerable scope for improving the relationship between health authority commissioning teams and lead clinicians in the service providers. Health authority purchasing during this period is an under-researched area, and this study contributes a detailed analysis of one aspect of the workings of the internal market in one NHS region during the mid 1990s. As a case study in policy analysis, this thesis offers insights into the policy process within the UK health care system, and the ways in which this operated within the changing policy arena created by the introduction of the internal market following the Government White Paper, Working for Patients.