Primary care trusts as commissioners of secondary care : three case studies
This thesis considers the commissioning of secondary care by Primary Care Trusts (PCTs). It provides an in-depth analysis of the commissioning relations and decision-making between PCTs and NHS Trusts using the underlying assumptions of principal-agent theory as a lens for investigation. This qualitative research adopted a range of methodological approaches including the use of observation, interviews and documentary evidence in the analysis of three case studies. The case studies each comprised an NHS Trust and up to four PCT commissioners. Commissioning-related meetings were observed in order to gain an understanding of the ways in which PCTs and NHS Trusts acted as principals or agents, and how these relations were managed. These were followed by interviews with managers and clinicians from primary and secondary care to complement the observational data and to investigate additional issues such as the impact of multiple principals and tiers of principals and agents. Service and Financial Framework documents and Service Level Agreements were also examined. Analysis shows that commissioning was approached in a different way in each case study. The factors affecting the approaches to commissioning were perceptions of local and national pressures, accountability, a public service ethos, leadership, trust and local history. Incentives were not used in Service Level Agreements. In each case study, there was a weak link in the principal-agent chain of commissioning that had the potential to result in non-compliance with decisions. This weakness arose either between commissioner and provider, or between managers and clinicians. In either case, the greater use of incentives is suggested as a solution. Some PCTs did not appear to accept the legitimacy of their roles as commissioners. In addition, and unusually, the principals had an agent role; PCTs were providers as well as commissioners. These dual roles created conflicts of interest.