Title: Understanding the new commissioning system in England: contexts, mechanisms and outcomes.
Funder: Department of Health and Social Care

Abstract: Background Current NHS reforms devolve more commissioning decisions to the local level and enable a renewed focus on outcomes. The new commissioning system is complex, involving many new organisations. Some of these closely resemble their predecessor organisations, whilst others are markedly different, covering widely differing population sizes and having different histories. The distribution of commissioning responsibilities is also different, with responsibilities previously held by single PCTs now distributed between CCGs, LA Commissioners and a new national body, NHS England. Thus, both structural and operational complexities have increased. This research will address the system as a whole, exploring how these organisations interact and investigating the extent to which outcomes are changing as a result. Aims The research aims to assess the impact of recent reforms on the operation and outcomes of the commissioning system. Our objectives are to explore: The new system at local level, investigating how the new organisations are developing, assuming their responsibilities, interacting, holding one another to account, and relating to new national-level bodies Relevant effects of the new system, seeking to demonstrate changes which may be associated with elements of this system, as well as explicating factors which may have enabled/inhibited these changes. The research will use a realist evaluation framework, seeking to identify mechanisms which underpin specific outcomes in particular contexts. Research questions provided in Aims/Objectives Research plan/methods We will combine national level quantitative study of outcomes of commissioning with qualitative and quantitative study in two areas exploring the factors which have contributed to any changes. Work comprises: Qualitative study of developing interactions between the new commissioning organisations in two geographical areas defined by newly constituted Area Teams (ATs), using interviews and documents analysis Qualitative study of commissioning five tracer services within these two ATs. Tracers have been chosen theoretically to illustrate important aspects of the new system. Methods will include interviews, documentary analysis and targeted observation Quantitative exploration of outcomes. Findings from the early qualitative work, our existing knowledge of the new system and previous research will be combined to develop candidate explanatory factors ( causal mechanisms ) that are expected to impact on the operation of the new system. A continuous difference-in-differences approach will be used in an analysis of the whole country to test the effect of these moderators on a range of outcomes (derived from routinely collected data). Further quantitative analysis of changes in selected outcomes associated with the tracer service areas across the whole country will allow comparisons between service areas where commissioning complexity remains low and those where complexity has increased. Quantitative findings will feed into a final stage of qualitative work, directing exploration of factors that have contributed to the revealed outcomes. Team The team combines experienced qualitative researchers of commissioning-related policy (Checkland, Allen, Coleman, Segar) a mixed-methods researcher knowledgeable about the policy and practice of commissioning (Mays) with an experienced applied econometrician/health policy economist (Sutton). Most of the team have worked together on a number of successful large projects on topics closely related to this, and Allen and Checkland work successfully together as Associate Directors of the PRP Policy Research Unit in Commissioning and the Healthcare System (PRUComm). PRUComm Director, Peckham, will contribute at no cost. Outputs /impact The study will generate learning relevant throughout the system. Understanding how the new organisations are working together, the causal mechanisms underpinning observed outcomes and the influence of context and degree of complexity of the local commissioning system on outcomes will inform the ongoing development of policy, support those responsible for enabling system development and provide front-line commissioners with useful evidence. This will benefit the NHS as a whole, ultimately improving patient care.

Lay abstract: The recent reorganisation of the NHS in England is intended to address some of its longstanding issues. The new system is designed to ensure that practising clinicians have greater autonomy to make decisions, and that the system as a whole focuses on outcomes. To achieve this, a number of new types of organisation have been created, with increased involvement of clinicians and the establishment of new accountability mechanisms. Given the magnitude of the changes involved, it is vital that their impact is evaluated. Research has shown that where complex groups of organisations work together, the outcomes seen depend as much upon the interactions between organisations as they do on the activities of each organisation alone. This research will therefore explore the new system for commissioning health care as a whole, addressing theme a in the specification. We will explore the roles and functioning of the parts of the new system, using detailed qualitative case studies of groups of organisations in a geographical area to investigate how the new organisations are working together and influencing one another. In the case study areas we will also study the commissioning of particular services, carefully chosen to illustrate different aspects of the new system. We will then combine this evidence with an economic analysis of the performance of health care organisations to draw conclusions about the way in which the new system is functioning, the extent to which outcomes are improving, and the factors which seem to be affecting this. The study will link evidence about quantitative changes in outcomes with detailed qualitative evidence about the way commissioning is being performed, allowing us to show how particular combinations of local context and behaviour by members of the new organisations are combining to produce observed effects. This team are well placed to do this because they have significant experience of similar research and have carried out large studies of different aspects of commissioning. In addition, they are currently working on a number of complementary studies, the results of which will feed into the design and conduct of this study.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE