Governance for health and wellbeing in the English NHS

Abstract

Objectives

Shifting the focus of health-care systems towards prevention has proved difficult to achieve. Governance structures are complex, incentives may conflict and there are many competing priorities. We explored the influence of governance and incentive arrangements on commissioning for health and well-being in the English National Health Service (NHS) and the governance paradoxes which emerge.

Methods

Qualitative and quantitative methods were employed. We carried out one national and two regional focus groups; a national online survey of primary care trusts (PCTs); and 99 semi-structured interviews in 10 purposively selected case study sites across England. Interviewees included decision-makers in PCTs, practice-based commissioners, Chairs of Local Involvement Networks (LINks) and of Overview and Scrutiny committees (OSCs) and Voluntary and Community Sector (VCS) members of local health and wellbeing partnerships.

Results

Case study sites differed in the extent to which they reflected a public health ethos throughout the commissioning cycle, incentivized preventive services through contractual flexibilities or prioritized investment in health and wellbeing. Practice-based commissioners were tangentially involved in the commissioning cycle, public health partnerships or local health needs assessment. While commissioning for health and wellbeing involves working through partnerships, performance management regimes favoured single organizational success. Preventive services were considered at increased risk in times of financial stringency.

Conclusions

As the NHS in England undergoes further reorganization, it is important to ensure that a systematic, strategic and population-based approach to commissioning is not lost. Governance and incentive arrangements should be critically assessed for their impact on population health and wellbeing.

Introduction

Policy commitments¹ and commissioning guidance² for health and wellbeing in the National Health Service (NHS) in England emphasize the importance of maintaining people's independence, investing in prevention and working across health and local government to tackle health inequalities. The costs to the NHS and the wider economy of failing to invest for health have been highlighted³ as has the importance of refocusing performance management systems and regulatory arrangements accordingly. Nevertheless, shifting the ‘gravity of spending'¹ towards prevention has proved difficult⁴ in the context of competing demands, comparative weaknesses of the commissioning function, the under-developed nature of the evidence base for public health interventions, and the lack of a ‘fully engaged’ public.

While governance structures and processes are intended to reflect underlying principles and values, these structures are complex, conflicting incentives are layered into health care systems and there are competing priorities. Although normative approaches to governance are contested, principles and processes of ‘good governance’ have been considered in relation to nations,⁵ public bodies,⁶ NHS boards,⁷ and reflected in standards for conduct in public life.⁸ However, different models of governance, such as participatory governance or partnership governance, may combine, cohere or conflict in practice.

The governance landscape is complex (Table 1) with a range of areas which could be considered for their impact on the governance of public health. For example, do current performance management regimes promote a focus on promoting health as well as on providing high quality health care? Is partnership governance effective and does public involvement have an impact on commissioning decisions? Primary care trust (PCT) commissioners can create incentives through provider contracts, local reward schemes, payments for carrying out specific services, arrangements to incentivize individual health behaviour or enhancements to the voluntary pay-for-performance element of the new General Medical Services (nGMS) contract for primary care practitioners, the Quality and Outcomes Framework (QOF). But how far are these used to incentivize health and wellbeing services?

Table 1

Approaches to governance

Principles/ values	Governance arrangements/ processes	Modes of governance	Levels of governance	Topic- based/ functions (examples)
Stewardship - health - economy - environment	Allocation of authority - roles and responsibilities - law and regulation - rights	Hierarchies (agency model)	Political/administrative	Clinical governance
Conduct Seven principles of public life (Nolan principles) (8)	Standards, targets and performance management regimes	Networks (stakeholder model)/partnership governance	System	Information governance
Good governance in public services - promoting values - focus on purpose and outcomes	Accountability arrangements - professional - public - political/democratic - vertical/horizontal	Markets (contractual)	Organisational (corporate governance)	Integrated governance
	Processes for ensuring transparency, effectiveness and managing risk	Hybrid forms	Multi- level	Digital governance
	Audit and inspection	Participatory governance	Community

A stewardship role is linked with notions of good governance, reflecting ethical concerns over the common good and the nature of civic engagement and responsibility. It has been argued that stewardship of the health of the population should be considered a hallmark of good governance. For example, the World Health Organization (WHO) argues that responsible management of the health of the population is the ‘very essence’ of good government,⁹ the Nuffield Council on Bioethics¹⁰ explored the stewardship model of the state, and the Marmot Review¹¹ considered the reduction of inequity in health as at the heart of governance. A stewardship role at local level is reflected in the requirement for primary care organizations and local authorities to promote the health and wellbeing of their populations. However, success in carrying out this role at national or local levels depends on the fit between this underlying principle and the governance structures in place as well as on abilities to negotiate complex arrangements involved in the governance of public health.

The NHS in England has been described as a combination, from its inception, of different modes of governance, that is, ‘quasi-hierarchy, quasi-markets and quasi-networks'¹² although, unlike Scotland and Wales, the English NHS has increasingly embraced elements of the market. However, complex and multi-factorial problems such as health inequalities and obesity, require collaborative, multi-agency approaches.

This article focuses on how the underlying principle of promoting health and wellbeing for a local population is reflected in the commissioning cycle, including incentive schemes; in performance management regimes; and in the attention paid to partnership governance and public involvement. It then explores a number of paradoxes which emerge.

Methods

Mixed methods were employed. An exploratory phase included three focus groups,¹³ a scoping study of public health governance and a review of economic perspectives on incentives, public health interventions and prioritization tools. Field work was carried out in ten sites selected to reflect urban and rural areas, population size, level of deprivation and selected performance measures. A total of 99 semi-structured interviews was carried out in two phases between 2008 and the end of 2009 with PCT decision-makers including directors of public health, non-executive directors and chief executives; general practitioner leads for practice-based commissioning; representatives from voluntary and community sector members of local health and wellbeing partnerships; chairs of Local Involvement Networks (LINks) and chairs of Overview and Scrutiny Committees (OSCs; Tables 2 and 3). Interviews were audio recorded and transcribed and a thematic analysis was carried out, supported by NVivo. Drawing on findings from the interviews, a national online survey, using the web tool SurveyMonkey, was carried out at the end of 2009. Responses were received from 95 PCTs (65%) with 138 individual responses.

Table 2

Recruitment for phase one interviews

	Case study site									Total
Interviewees	1	2	3	4	5	6	7	8	9	10
Chief executive	R	R	R	D	D	D	D	D	D	D	3
Director of commissioning/strategy	R	R	RT	R	R	R	R	R	RT	RT	10
Director of public health	R	RT	-	RT	Rx2	R	R	R	RT	R	10
Director of finance	D	R	RT	R	R	R	R	D	R	D	7
Non-executive director	R	D	R	R	R	D	R	D	R	RT	7
PEC chair	R	R	R	N/A	R	D	D	R	R	R	7
PBC lead	D	RT	RT	D	Rx2	R	R	RT	RT	D	8
Health scrutiny committee chair	R	D	R	Rx2	D	R	D	D	D	R	6
LINk chair	N/A	N/A	R	N/A	R	R	R	R	R	D	6
VCS member of health partnership	R	R	RT	RT	R	R	D	R	R	R	T	10
				R
Additional interviewees	1			1	2						4
Total	8	7	9	9	12	7	6	6	8	6	78

R = recruited (face to face interview)

D = declined

RT = recruited (telephone interview)

N/A = not applicable or post not filled

Table 3

Recruitment for phase two interviews

	Case study site
Interviewees	1	2	3	4	5	6	7	8	9	10	Total
Chief executive	–		–	–	–	–	–	–	–	–
Director of commissioning/ strategy	D	–	–	R	–	–	RT	D	D	RT	3
Director of public health	R	RT	RT	–	Rx2	RT	RT	RT	D	D	8
Director of finance	–	–	–	–	–	–	–	–	RT	–	1
Non–executive director	–	–	–	–	–	–	–	–	–	–	–
PEC chair	–	–	–	–	–	–	RT	–	–	–	1
PBC lead	R	RT	–	–	R	–	–	–	–	RT	4
Health scrutiny committee chair	–	–	–	–	–	–	–	–	–	–	–
LINk chair	–	–	RT	R	–	RT	–	–	–	–	3
VCS member of health partnership	–	–	–	–	–	–	–	–	–	–
Additional interviewees									1		1
Total	2	2	2	3	2	2	2	2	2	2	21

Results

Commissioning for health and wellbeing

Focus group participants debated the complexity of the governance landscape for public health, highlighting changing notions of stewardship, from top-down collective approaches to an emphasis on individual choice, the importance of governance arrangements across a local health system and timely action on emerging heath hazards.¹³ For PCT interviewees, however, the concept of governance was often associated with processes for accountability, meeting targets, maintaining financial balance and identifying and mitigating risks.

There were differences between sites in the extent to which: a public health ethos was reflected in the commissioning organization and throughout the commissioning cycle; preventive services were incentivized within primary care; and preventive health spend was tracked as a means to prioritize investment in health.

In some sites, commissioning was public health-led while in others an advocacy role was highlighted:

A fundamental part of our role is to get resources out of traditional commissioning and into lifestyle services … I don't think that means that we need to sit on each commissioning group (Director of Public Health)

However, the importance of leadership and board culture in promoting a preventive agenda was emphasized:

Our non-executive directors on the board are very much focused on the whole health inequalities agenda and … there is no doubt the whole health inequalities agenda is now running through the organization like the words on a bit of rock (Director of Finance)

While practice-based commissioning (PBC) was established in 2004 to engage primary care clinicians in commissioning, interviewees in most sites described minimal involvement with a proactive approach to health and wellbeing and variation in the engagement of public health teams with PBC consortia. PBC needed skills in commissioning on a larger scale, in more complex areas, and in developing strategy:

And for me it's always been an issue with practice-based commissioning … I went through five years of specialist training to come out as a commissioner about the needs of the population. Overnight we expected these people, whose whole training, whose whole raison d'être for getting out of bed in the morning is about the individual, and very few of them have got a mindset beyond that. So I think it's really, really difficult (Director of Public Health)

Conflicts between commissioning and provider roles of PBC were seen as inevitable, although some interviewees were confident that their governance structures provided effective firewalls between the two functions. There were variable levels of patient involvement with PBC clusters and an often tangential relationship between PBC and the commissioning cycle. There was little involvement in joint strategic needs assessments (set up in 2008 to identify health needs across a local authority area) or in local health partnerships.

Incentives for health and wellbeing

Incentives are available for involvement in PBC and 70% of savings from managing demand for acute services may be made available to PBC through the PCT for developing services. In practice, however, this depended on the financial situation of the PCT and was influenced by the extent of overspend in other practices. While available savings acted as an incentive to reduce the demand for acute care, they did not provide an incentive for providing preventive services, as savings were difficult to quantify or release in the short-term. Some PCTs were making savings recurrent to encourage a more strategic approach or pooling savings across practices to encourage collaborative bids.

The national survey showed that Local Enhanced Services (LESs), an optional and locally determined element of the nGMS contract, were the most commonly cited incentive for preventive services such as assessment for cardiovascular disease risk, smoking cessation and falls prevention in primary care. LESs were viewed as an effective and flexible approach to meeting targets and addressing gaps in the QOF such as the proactive identification of populations at risk. However, their use was piecemeal and fragmented, they could be withdrawn in periods of financial stringency and if they were not taken up by targeted practices, they could increase inequalities in provision.¹⁴

Over reliance on transactional approaches was criticized given that collaborative commissioning was also important. For example, local primary and secondary care clinicians could collaborate with social services to manage a budget, or a local network of general practitioners (GPs) could be provided with a budget for a specific pathway of care which would also incorporate preventive services.

Preventive services, such as smoking cessation, could be incentivized through acute contracts through the commissioning for quality and innovation initiative. However, it was pointed out that these targets were difficult to monitor and it was possible that some interventions, such as smoking cessation, would be better located in primary care.

Although much could be achieved through incentives, interviewees commented that their impact would be reduced if incentives in the system worked against each other or failed to cohere. While there were incentives for PCTs to manage demand through practice-based commissioning, as failure to do so would threaten their financial viability, secondary care providers were incentivised to increase activity. One interviewee commented:

At the other end of the spectrum you've got foundation trusts who as a requirement of their operating licence with MONITOR … produce a surplus. So they have no incentive to do other than to suck more and more work into their hospital. (Director of Strategy)

Over the course of the project, interviewees emphasized the importance of performance management, new contracts and contract specifications (including a clear specification of core contracts) in primary care and noted that transactional approaches could serve to undermine local involvement.

Prioritizing investment in health and wellbeing

Making decisions over investment and disinvestment are key tasks for commissioners.

While investment in preventive services had typically been funded through growth money, future investment required successful disinvestment strategies. Although some interviewees were optimistic that preventive services would be protected in a period of economic downturn, much would depend on how acute sector demand was managed. Preventive initiatives could be at-risk, given that benefits were long-term and a lack of preventive services did not lead to a public outcry:

You know, there are not ten thousand disappointed people who are fed up because they're not getting something to stop them getting bronchitis or lung cancer in five or ten years’ time. (Director of Public Health)

However, economic stringency could also spur radical restructuring and whole system investment and interviewees emphasized the importance of demonstrating cost-effectiveness and return on investment for health and wellbeing initiatives:

And so I think that the economic argument for the public health investment needs a lot more research and development and a lot more strengthening because it's stacked up against an economic argument that's compelling from the health care providers. (Non-Executive Director)

However, in focusing on prioritizing investment within PCTs there was a danger of focusing solely on the NHS, missing possibilities for partnerships to work together on the health and wellbeing agenda.

Commissioning priorities were initially informed by joint strategic needs assessments and against this backdrop, interviewees described a range of prioritization tools. New proposals were often prioritized through locally-developed prioritization matrices and around 25% of PCTs that responded to the survey appeared to have developed their own tools.

A second approach was to prioritize across a programme, examining the cost-effectiveness of each initiative in relation to effects on morbidity and mortality, possibly segmented by different groups, and including some consultation with the community.

A third approach was to use national programme budgeting data as a benchmarking tool in order to identify outlier areas, priorities for investigation and possible sources of savings. This was often useful where there was little cost-effectiveness data available and could also highlight areas for investment in preventive services and primary care. While the methodology was considered useful, there were concerns over the timeliness and quality of data: programme budgeting was not designed for joint planning in relation to children's services, for example. There were also concerns among a number of interviewees that this approach did not help determine resource allocation across preventive and acute care for specific care pathways, such as cardiovascular disease, where some elements were hidden in other programme areas. Only a minority of sites had used programme budgeting and marginal analysis.

The fourth approach was prioritizing in relation to different demographic and financial scenarios, which could include modelling the impact of unhealthy lifestyles over the longer-term. However, methods for prioritizing investment across all spend and scenario modelling within the NHS or in partnership with local authorities were underdeveloped and influenced by the quality of the evidence for public health interventions.

There were concerns over the suitability of existing prioritization tools for modelling costs and benefits of investing in health gain over the longer term, prioritising across all areas (as opposed to programme-specific analysis), or identifying inter-sectoral impacts. There were also limits as to what such tools could offer:

We've all agreed there's no science to it. There's no magical tool that's going to give you the answer and say you should do this beyond that. You know, there are a range of factors that you're going to have to take into account from needs and the financial situation and the political situation and where the public is coming from. (Director of Public Health)

Identifying spending on prevention

Monitoring shifts in investment towards prevention requires identification of preventive health spend. This was considered difficult, if not impossible, to define given the number of contexts in which preventive care was delivered. Interviewees often understood such spending as growth money which had been allocated for health inequalities or lifestyle interventions, or as resources under the control of the public health team. In two sites, however, resources were clearly aligned to shifting the balance of spend towards prevention through the use of (reworked) programme budgeting data and reflected in annual percentage increases in preventive health spending.

Performance management regimes

An emphasis on achieving standards and targets as an indicator of effective governance raises questions over the extent to which the configuration of targets, standards and regulation promotes a preventive agenda. Not all targets were subject to the same level of scrutiny. Despite national targets for narrowing the health gap, this proved no guarantee for their being prioritized in practice. There was a hierarchy of targets, electoral cycles predisposed to short-term targets, and only some targets, such as control of health care acquired infections or the 18 week limit on referral to treatment time, were considered career limiting. Central priorities remained the main focus as reflected in performance management as well as by external regulatory bodies. The national survey reinforced the view that performance management played a relatively minor role in supporting a health and wellbeing agenda, with only 14.9% of responses strongly supporting their role compared with 63.2% of responses strongly supporting the role of board values.

Preventive services were often described as an ‘earned agenda’ and at risk if resources were not released from elsewhere in the health care system.

The assurance framework for world class commissioning² provided an influential (if rather separate) performance management regime and had encouraged a systematic approach to improving health outcomes. However, ‘commissioning for health and wellbeing’ was ambiguous and many interviewees considered it synonymous with ‘commissioning', spanning preventive and acute care. This risked diluting its original public health and preventive focus. Despite the importance of partnership arrangements for improving health outcomes, the framework did not apply to local authorities, which could lead to a lack of consistency and did not incentivise the development of shared priorities.

While clinical governance was recognized as a key assurance framework for NHS organizations, a number of interviewees considered a systematic approach to public health, equivalent to that developed for clinical governance:

So it would be quite interesting to … take what we apply to clinical governance and debate whether you have the same thing in public health. So do you have people clearly in charge of it, have we got the right training courses so our staff are appropriately skilled, have we got the right processes that will get the right bits of public health in the right order? Does the board pay significant attention, does it receive the appropriate reports at the appropriate time? So it would be quite an interesting line of thought. (Assistant Chief Executive)

Partnership governance

Focus group participants commented on the importance of a ‘governance of place’ and effective stewardship across a local public health system. Most interviewees emphasized that partnerships were key for commissioning health and wellbeing services. Indicators of success included the extent to which joint strategic needs assessment had influenced priority-setting in both the PCT and the local authority; scenario modelling across PCTs and local authorities to identify the potential impact of changing health needs; joint posts including, but not limited to joint directors of public health; the inclusion of local authority members in care pathway development; shared approaches to performance management across local authorities and PCTs; and the creation of pooled budgets and other joint commissioning arrangements for health and wellbeing. The latter included initiatives for weight management, smoking cessation, physical activity, and local neighbourhood approaches.

However, partnership governance was identified as a weak area, particularly at the interfaces of interagency working. Governance issues related to cultural differences between organizations; tensions between democratic accountability and other forms of accountability and representation; ambiguities in carrying out joint director of public health roles; and difficulties in targeting effort given the breadth of the agenda. Partnerships were subject to continual changes in membership and structure; aligning priorities was difficult across large geographical areas or where PCTs and local authorities were not coterminous; there was little external scrutiny of partnerships and governance arrangements around joint commissioning needed strengthening. ‘Silo’ working in public health and the lack of integrated multi-agency structures were indicators of governance failure.

Performance management regimes and incentives were described as geared towards the success of single organizations rather than partnerships, with tensions between national targets and local priorities. While there had been attempts to align the assessments of national regulatory agencies and monitor outcomes across a local authority area through the comprehensive area assessment (subsequently abolished), alignment was more evident at a strategic than at a local level. Performance monitoring of joint targets for health improvement, agreed through local strategic partnerships, was relatively neglected.

Some interviewees were concerned that financial stringency would promote ‘cost shunting’ across organizations, with each organization focusing on its own boundaries and budgets. Others thought the opposite -that a lack of resources would encourage organizations to share functions, making the best use of limited resources. In one of the sites, stakeholder meetings across the local health economy had been held to consider effects of the financial crisis and to ensure that decisions were not made in isolation:

Because the danger in all of this is that if you do something in one part of the economy and it has an unintended or sometimes intended consequential effect somewhere else you just move the problem. We want to avoid that… and I think the only way you can really do that is truly understanding what all of the partners’ strategic direction and intentions are so that we aren't creating additional problems for ourselves. (Director of Finance)

Participatory governance

Policy guidance emphasizes the role of patient and public involvement at each stage of the commissioning cycle and interviewees described a panoply of methods for engaging patients and the public including stakeholder events, patient panels and focus groups, ‘health conversations', telephone surveys, patient representatives at PCT board level, open sessions with the public prior to board meetings and joint initiatives across PCTs and local councils. Public involvement in PBC was still under development in many of the sites. Interviewees commented on difficulties of engaging the public, ‘single issue’ representatives, and inadequate engagement with disadvantaged or transient populations. However, there was a relative lack of interest in population health:

The problem we've got with public involvement, as a concept, is that we tend to involve people who are or have been ill to get into these decisions because their experience of the service allows them to bring a perception or a perspective to the purchasing of future services. Of course what we're trying to do here is to involve the people who've never been ill … and so involving the public in public health is quite a difficult thing to do. (Non Executive Director)

OSCs often focused on health care rather than partnerships, preventive services or health protection. They were rarely mentioned in PCT accounts of governance.

LINks were established in 2008 to give citizens a ‘stronger voice’ in how health and social care were delivered. There was variation in the impact, level of understanding and development of LINks. In one site, the LINks chair held a non-voting seat on the PCT board and was a member of a wide range of committees. However, in other sites, LINks were considered as just one of a wide range of community inputs. There was little influence on social care services and a consultative rather than a formal decision-making role predominated. The majority of LINks chairs had little or no input into priority-setting and most were yet to form relationships with partnerships such as Local Strategic Partnerships (LSPs) or with practice-based commissioning.

Interview data demonstrated that PCT interviewees were more satisfied with the level of engagement than were members of voluntary and community sector organizations who commented on the lack of influence and inadequate feedback over decisions.

Discussion

Generalizability of case study findings is limited by the focus on ten sites. The recruitment of sites and of interviewees was largely as anticipated, although delays in setting up LINks nationally were reflected in our sites. Focus group participants were few in number. Following the election of a new government in 2010, the White Paper ‘Equity and Excellence: liberating the NHS’ signalled major changes in the governance of the NHS. These included the abolition of PCTs and OSCs, and the creation of GP commissioning consortia. However, generic issues related to commissioning for health and wellbeing remain relevant, as does the complexity of governance of public health, which goes beyond the governance arrangements of any single organization.

The impact of governance structures on commissioning for health and wellbeing reveals a number of contradictions: the stewardship role is changing and is sometimes narrowly defined; there is an enduring emphasis on governance within the NHS despite the importance of joint working in commissioning for health and wellbeing; a hierarchy of targets does not prioritize prevention; incentive schemes for preventive services in primary care are optional; and contextually relevant prioritization tools need development in order to assess costs and benefits of investing in health and wellbeing over the longer-term. Moreover, commissioners need a clear understanding of the strategic potential of contractual flexibilities and incentives, as well as of the potential pitfalls of incentives, acting singly and in combination.

While there are shifts towards local priorities and increased public accountability, these co-exist within hierarchical forms of governance. A market mode of governance has limited applicability to partnership working and collaborative commissioning which are increasingly viewed as routes for limiting both ‘risk shunting’ across commissioners and providers and ‘cost shunting’ across different parts of the local health system.

Leadership qualities are required for negotiating a path through the complexity of governance arrangements for public health. While clinical governance has influenced quality assurance frameworks in the NHS, a sister concept of ‘public health governance’ has not been adequately operationalized. While a proliferation of topic-based approaches to governance can lead to fragmentation, the concept of ‘public health governance’ serves to highlight the range of issues arising in the governance of public health including how far a focus on health and wellbeing is reflected throughout the commissioning cycle, in priorities for investment, performance management and the use of incentives and contractual arrangements. It is closely associated with the stewardship role, and as such, with values which should inform the wide range of governance arrangements that currently co-exist.

As the new UK government reshapes governance arrangements it will be important to ensure that such arrangements are critically assessed and realigned to promote preventive services which are key for the longer term sustainability of the NHS. For example, with the abolition of PCTs, how will joint strategic needs assessment influence the commissioning intentions and priorities of new GP commissioning consortia? How will responsibilities be negotiated between these consortia and proposed local authority-based health and wellbeing boards? And how will public and patient involvement in commissioning be achieved? Through an outcomes-based and systematic approach, a public health-led model of commissioning was encouraged, but in future what will be the role of public health teams in GP consortia, in incentivising preventive services and in prioritizing investment? Moreover, there will be dual accountabilities to the planned national public health service and to democratically accountable local authorities.

It is important that shifts in commissioning responsibilities do not weaken a strategic and population-based approach to improving health and addressing health inequalities through the entirety of the commissioning cycle.

Footnotes

Acknowledgements

The authors would like to thank interviewees for giving up their time to be interviewed for this project as well as those who responded to the national survey. We would also like to thank Kate Melvin for interview support.

This study forms part of a research project ‘Public health governance and primary care delivery: a triangulated study’, funded by the National Institute for Health Research Service Delivery and Organisation Programme (project number 08/1716/208). The views and opinions expressed are those of the authors and do not necessarily express those of the NIHR SDO programme or the Department of Health.

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