The search results are summarised in Figure 1. We identified 2166 references, scanned 133 titles and abstracts and retrieved 42 publications for full texts. From these, we included six studies (including a total of 1155 participants) that reported data on clinical commissioning and health inequalities46-51 and excluded 36 studies (Additional file 2). Of the six, four were qualitative.46-49 All studies were conducted between 2010 and 2017 and the list of included studies is presented in Table 2.
Table 2 Summary of reviewed studies
Author
|
Aims/study question
|
Study type and method
|
Dates
|
Participants
|
Key findings
|
McDermott et al.46
|
To analyse how CCGs have responded to the new responsibility and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems
|
- Qualitative - exploratory approach
- Data were collected using interviews and national telephone surveys
|
2015-2017
|
112
|
Integration of budgets and commissioning responsibilities; CCGs understood the roles of primary and local needs, new models of care
|
Turner et al.47
|
To inform current debates by reporting findings from a series of in-depth interviews
conducted with a range of experienced professionals
working in varied roles within the health and social care
commissioning arena
|
- Qualitative methods
- Data were collected using semi-structured and in-depth interviews
|
2012
|
42
|
Community did not feel any progress on the issue of health inequalities but reported better management due to partnership, commitment and strategic programme approach
|
Cheetham et al.48
|
To examine the factors affecting the design,
commissioning and delivery of integrated health and wellbeing services (IHWSs), which seek to address multiple health-related behaviours, improve wellbeing and tackle health
inequalities using holistic approaches
|
- Qualitative methods
- Semi-structured interviews and evaluation were conducted to collect data
|
2015-2016
|
16
|
Challenging organisational context but realised long-term benefits to population health and wellbeing
|
Salway et al.49
|
To what extent and in what ways are ethnic diversity
and inequity considered within healthcare commissioning?
What factors influence this commissioning practice?
|
- Qualitative method
- Data were collected by semi-structured interviews
|
2010-2013
|
89
|
Tackling health inequalities not considered as part and parcel of commissioning
|
Al-Haboubi et al.50
|
To explore: (i) whether
there are inequalities in the use of dental services
among adults residing in a socially deprived, ethnically
diverse metropolitan area; (ii) satisfaction with services
provided; and (iii) public perceptions on possible areas for improvement of local services
|
- Cross-sectional quantitative
- Data were collected using structured questionnaires
|
not provided
|
695
|
Community felt positively in terms of service improvement, affordability and accommodation
|
Gadsby et al.51
|
To examine key changes to the public health
system following the reforms, and explores the broad function of commissioning for health improvement within the new system
|
- Mixed methods
- Data were collected employing multi-methods – web-based questionnaire survey and in-depth case studies
|
2014-2015
|
201
|
Raised issues of time, costs and relationship between commissioners and local authorities but positively influenced the prioritisation and decision-making process
|
Synthesis of evidence
This study is organised under four major themes/findings which emerged.
Finding 1: An overwhelming majority (5 of 6 papers, 83%) of the papers indicated the agenda of health inequalities has not given priority by clinical commissioning
The primary and overriding finding of this study is that clinical commissioning (CC) has not given health inequalities as a priority agenda of the commissioning process. Some evidence indicated that CC was more considered a public health activity to determine health needs of individuals or populations by identifying, assessing and prioritising their needs and actions as general public health functions rather than commitment to reducing health inequalities.46 One paper, however, reported that CC has been used as a tool to improve service improvements to address inequalities.47 Participants expressed these aspects thus:
Commissioning was considered as one of the broad aspects of public health activity […] identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance.51
Responsibility for the health inequalities agenda was seen primarily as a function of public health roles rather than part and parcel of core healthcare commissioning work, even where PCTs had adopted explicit strategic priorities relating to inequalities.47
CCGs understand primary care and local needs. Allowing CCGs to commission primary care alongside other services would support the development and implementation of local strategies for service improvement, support innovation in primary care and allow investment in primary care (by allowing resource shifting).46
Finding 2: More than half (4 of 6, 67%) of the papers reported reform through restructuring and organisations, and strategic approaches in collaboration, commitments and engagement as benefits of commissioning in healthcare.
The benefits of clinical commissioning have been reported across different studies. Based on further analysis of the papers, three major benefits emerged:
a) Context and restructure of services: Since the Health and Social Care Act (HSCA2012), the commissioning process has been much better in terms of understanding the wider social-political context of local healthcare, recognising wider consultation on decision-making to plan and deliver health services involving local elected people and organisations. Similarly, this reform has relocated public health from NHS to local government, and prepared staff for transition to deliver integrated approaches.51(p.4) The following extracts illustrate issues relating to service context and restructure:
The relocation of public health from the NHS to local government provided important context for the introduction of IHWSs. Participants in both sites felt there were new opportunities to work across local authority directorates to address the wider determinants of health and health inequalities.48
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.51
b) Strategic approaches - service integration and commitment: CC offers greater knowledge and understanding of integrating local health services reflecting data to local health plans. McDermott et al.46 (p.7) further add that “Integrated care [in the context of CC] requires detailed local work to build trust and develop context-specific mechanisms to work across boundaries.” Similarly, a great commitment through investment has been given within council services to improve public health to meet needs and expectations. Included papers reported these aspects as follows:
Potential for greater integration of knowledge and data on local communities, stronger JSNAs and better understanding of needs, was noted with the move of public health to Local Authorities. In addition, new structures, particularly the HWBB, created the possibility of new opportunities for representation.47
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.51
Both local authorities had a long-term strategic commitment to community development and asset-based approaches, which was seen as beneficial by public health commissioners.48
c) Partnership and engagement: The association between CC and wider healthcare partnership and engagement has been reported positively in terms of meeting healthcare needs by reducing duplication costs/resources and sharing knowledge and expertise. These studies conveyed this view:
Expressed concerns that CCGs would have to start a lot of community engagement work from scratch, and develop meaningful relationships with key communities. Engagement was seen by many participants to be important not just for understanding population needs, but also in commissioning services that effectively meet those needs.47
…recognised and articulated the potential added value of collaborative working between NHS and local authority partners, plus the third sector in WFL. Anticipated benefits included reducing duplication, extending the reach of existing services and programmes, sharing expertise and capacity and maximising opportunities for innovation. The idea of offering a more streamlined accessible approach, which seeks to knit together a number of different functions was broadly welcomed.48
GPC endorsement of the social model of health underpinning LWG and WFL, there was also broad acceptance of prevention and early intervention, recognised as being more cost-effective than long-term treatment.48
Finding 3: All six papers (100%) indicated that there was some poor evidence for reducing health inequalities through the clinical commissioning process, primarily due to poor approaches utilised in decision-making, lack of budgets, time, strategic priorities, and poor commitments.
These barriers have been broadly categorised into two levels:
a) Structural impediments: all papers reported that in commissioning, the decision-making process was a challenge as it demanded wider consultation with a range of policy-planners, politicians, and decision-makers at local levels. Similarly, studies reported commissioning responsibilities have been fragmented between different organisations (NHS England, PHE, local councils and CCGs), and co-ordination was slow, difficult and bureaucratic.48,51 Therefore, there was serious concern raised not only about diluting local authorities’ action on health inequalities but also failing to recognise and reduce health inequalities because of poor direction from central government and poor commissioner engagement in health services commissioning.47,49 The extracts below illustrate this:
Decision-making within councils was found to be very different to that within PCTs. 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.51
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 to streamline their organisations and reduce staffing costs. The positioning of public health teams within councils varied.51
Poor track record of shifting resources out of secondary care and into the types of primary care and public health interventions felt to be capable of achieving a significant impact on health inequalities.47
b) Personal impediments. More than half of the papers reported personal impediments (3 of 6, 60%) to reducing health inequalities in the CC process. Commissioners’ inadequate level of knowledge and expertise, poor trust/relationships between local authorities and staff involved in the commissioning process, poor partnership, working in different geographical locations and engagement, and a largely pessimistic approach have been reported as major challenges.47 Some extracts below illustrate this:
Most commissioners did not view identifying and tackling ethnic inequalities in healthcare access, experience or outcomes as part-and-parcel of their job due to lack of clarity about their responsibilities.51
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.51
Similarly,Pressures to get both services ‘off the ground’ quickly, coupled with different organisational cultures, a history of competing for contracts and mistrust arising from short-term contracts and reducing budgets, may have destabilised early efforts to build relationships among staff and with communities.48
Finding 4: Most papers (4 of 6 papers, 67%) indicated improving health services, appropriate policy and approaches should be in practice
These studies reported service improvement associated with availability, affordability, and accommodation or flexibility of services.50 Similarly, organisational contexts, appropriate translating of evidence into practice, were factors reported that influence health services locally improving. The extracts below highlight some relevant issues:
Staff, costs, and opening hours were the commonest areas where participants made recommendations for improvements to local dental services.50
Greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards.47
Investment and opportunities contained in national and local initiatives were seen as major contributors to enabling CCGs achieving a people-centred, locally driven,integrated primary care service with general practice.46
Fig. 2 is a conceptual framework (CF) that emerged from this study, noting that making the commissioning is a continuous assessment process. To make the effective link between CC and reducing health inequalities, this will give a stronger link between public health and broader work on the social determinants of health; putting people at the centre of the framework ensures their needs are appropriately met by providing best-quality care in primary care services. The approach would also give more immediate results in improving public health, making it part of the local political landscape.52 It is therefore important to routinely monitor the inequalities in access and health outcomes. This CF also acknowledges the skills and capacities of GPs and other healthcare providers in leadership and governance, and ensures they can fulfil their operational and strategic roles.53,54