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Purpose The paper reports on the findings of a survey of 115 (76 per cent) of English local authorities in 2016 which compared progress on the implementation of the Making Safeguarding Personal (MSP) approach in local authorities through their Adult Social Care departments and in relation to their area Safeguarding Adults Boards (SABs) and partner organisations. The purpose of this paper is to evaluate the survey in relation to personalised social care and its impact on organisations, their staff and service users, and conclude with wider implications and recommendations for further work.Design/methodology/approach A series of guided interviews were conducted with safeguarding leads from a sample comprising of 115 (76 per cent) of English local authorities during May and June 2016. The sample was randomly picked and balanced to give a fair representation of the different types of councils. The interviews were conducted by a team of five people. All interviewers had in-depth experience of adult safeguarding and were currently practicing independent chairs of SABs. The interviewers followed a prepared schedule consisting of a mixture of open and closed questions. All interviews were held over the phone and averaged one-hour duration.Findings The results pointed to the impression that the majority of local authorities had completed the first step of introducing MSP, i.e. they had trained their workers and modified their systems. Most local authorities were moving into the next phase of embedding user-focussed work into their practice and culture, and were at various points along that journey. However, most had still to engage partner organisations beyond a mere acceptance of MSP as “a good thing”.Research limitations/implications The research has wide ranging implications for organisations and their workers in the field of adult safeguarding based on its findings. Its limitations are that only organisational leaders and managers were interviewed, although reference is extensively made to initiatives that engage service users. The authors acknowledged the possible bias of interviewees when judging the performance of their own service and attempted to moderate their views in the final report.Practical implications The report references many practical implications to improve the practice of adult safeguarding in an attempt to make it more person-centred. Examples of good practice are given and recommendations are made to organisations.Social implications It is recognised that there are many people who may be at risk of harm through their environmental, personal, age or disability-related situations. In improving the way that services respond to their needs, they will be made to feel safer and their lives enhanced.Originality/value This original research follows up previous research in the preceding year. It is the widest ranging in its coverage of 76 per cent of English local authorities. Its value is that it measures progress towards full implementation of MSP; reports information and views from safeguarding leaders; and makes 20 recommendations to improve the implementation of MSP within local authorities, SABs and their partners. [ABSTRACT FROM AUTHOR]

Purpose This paper reports research undertaken into the practices, processes and outcomes of joint commissioning at five English localities. This paper reflects on the implications of this study for the practice of joint commissioning. Design/methodology/approach A case study approach to the research was adopted where the assumptions about what joint commissioning should deliver in five "best practice" sites. These hypothesised relationships about organisational processes, services and outcomes were then tested through the collection of primary and secondary data. Methods of data collection included an online tool based on Q methodology, documentary analysis, interviews and focus groups. Findings - Very little of what we found seemed to relate directly to issues of joint commissioning. Respondents often spoke of joint commissioning conflating it with issues of commissioning or joint working more generally. We found a variety of different definitions and meanings of joint commissioning in practice suggesting that this is not a coherent model but varies across localities. Little evidence of improved outcomes was found, due to practical and technical difficulties. Research limitations/implications -Joint commissioning is not a coherent model and is applied in different ways across different contexts. As such we may need to ask very different questions of joint commissioning to those typically asked. Practical implications - It is important that local sites are clear about what they are trying to deliver through joint commissioning or else risk that it becomes an end in itself. Some of the current reforms taking place in health and social care risk pulling apart existing relationships that have taken significant time and resource to develop. Originality/value - This is one of the first large-scale studies of joint commissioning conducted in England. [ABSTRACT FROM AUTHOR]

The research goals were to obtain an understanding of who the users of e‐books in the NHS are, what they are using e‐books for, and when and how they use them. This article presents the methodology used and the findings from the research. It also explores the outputs and next steps from the research, both for the individual countries and collectively. The Five Nations group, (library leads in England, Northern Ireland, Ireland, Scotland and Wales) commissioned research into healthcare staff use and non‐use of e‐books to understand the behaviours, needs and expectations of healthcare staff and to identify shared challenges around e‐books to inform policy and practice. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to present the findings of a small-scale evaluation of the Department of Health “Homeless Hospital Discharge Fund” (HHDF) in England. Design/methodology/approach – The paper is based on a mixed-method approach comprising 52 telephone interviews with project staff, 48 responses from an online survey with staff, outcomes data collected by projects, 30 semi-structured interviews with patients and nine in-depth telephone interviews with staff and commissioners. Findings – Overall the 52 pilots funded under the “HHDF” provided positive health and accommodation outcomes for homeless people admitted and discharged from hospital. In contrast to previous studies patients described not feeling judged during their stay, however the admission process was a more mixed experience due to communication breakdown by hospital staff. Integrating housing and clinical staff in the hospital discharge projects produced better outcomes for patients and the availability of accommodation as part of the model allowed improved and more stable housing outcomes. We recommend integrated commissioning takes place for future funding of any hospital discharge projects. Research limitations/implications – The study was small in scale and carried out before some of the projects had become fully established. The data were self-reported and the quality and completeness varied between projects. Originality/value – This is one of the few examples of hospital discharge outcomes for homeless people across a number of different localities and project models which examine the role of both health and housing professionals in the process. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to understand how inspection team members work together to conduct surveys of hospitals, the challenges teams may face and how these might be addressed. Design/methodology/approach Data were gathered through an evaluation of a new regulatory model for acute hospitals in England, implemented by the Care Quality Commission (CQC) during 2013-2014. The authors interviewed key stakeholders, observed inspections and surveyed and interviewed inspection team members and hospital staff. Common characteristics of temporary teams provided an analytical framework. Findings The temporary nature of the inspection teams hindered the conduct of some inspection activities, despite the presence of organisational citizenship behaviours. In a minority of sub-teams, there were tensions between CQC employed inspectors, healthcare professionals, lay people and CQC data analysts. Membership changes were infrequent and did not appear to inhibit team functioning, with members displaying high commitment. Although there were leadership authority ambiguities, these were not problematic. Existing processes of recruitment and selection, training and preparation and to some extent leadership, did not particularly lend themselves to addressing the challenges arising from the temporary nature of the teams. Research limitations/implications Conducting the research during the piloting of the new regulatory approach may have accentuated some challenges. There is scope for further research on inspection team leadership. Practical implications Issues may arise if inspection and accreditation agencies deploy temporary, heterogeneous survey teams. Originality/value This research is the first to illuminate the functioning of inspection survey teams by applying a temporary teams perspective. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to explore the nature of clinical commissioning groups (CCGs) in England as membership organizations. Utilizing the concept of meta-organization as a lens, we discuss the impact that this organizational form might have on CCGs' ability to become 'strategic commissioners'. Methods: We used a longitudinal qualitative approach to explore the adoption and implementation of primary care co-commissioning. The study was undertaken between May 2015 and June 2017 and included interviews with senior policy makers, analysis of policy documents, two telephone surveys, and case studies in four CCGs nationally. Results: CCGs operate as membership organizations with closed boundary and low stratification, whereby a consensus or majority needs to be reached by members when activities impact on membership or the CCG's constitution. While CCGs should move towards a more strategic commissioning role that is focused on local priorities agreed by their members, they are faced with a complex system of accountabilities and responsibilities, which makes this difficult to achieve. Conclusions: The nature of CCGs as membership-based meta-organizations has the potential to both help and hinder CCGs in becoming strategic commissioners. The complexities in accountability and governance that the membership approach introduces, and the potential difficulties that CCGs face with competing meta-organizations, raises questions about the future of CCGs as membership organizations. [ABSTRACT FROM AUTHOR]

While debate on how best to pay for social care in England continues, information about public attitudes on this issue is limited. We asked representative samples of the public whether care costs for older people should be met by the state, met by the service user or shared between state and user. We used an online survey of people aged 18–75 (n = 3,000) and interview survey of people aged 65 and over (n = 466). Respondents were given four vignettes (two home care, two residential care) and asked who should pay at different levels of user resources; and how much users should contribute when costs were shared. Fewer than one-fifth of the online sample and one-quarter of the interview sample considered that the state should meet the full costs whatever users' resources; considerably lower proportions believed that users should meet the full costs in all cases. Two-thirds of the online sample and half the interview sample thought costs should be shared. The proportion of costs that users should contribute was relatively low (20–50 per cent, varying by user resources). The study illustrates that public views elicited through vignettes can provide evidence to inform policy on social care funding. [ABSTRACT FROM AUTHOR]

Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a highlevel summary. Results We found an almost universal desire to provide the best quality of care. We identified many 'bright spots' of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported. [ABSTRACT FROM AUTHOR]

This project sought to describe the involvement of doctors in leadership roles in the NHS and the organisational structures and management processes in use in NHS trusts. A mixed methods approach was adopted combining a questionnaire survey of English NHS trusts and in-depth case studies of nine organisations who responded to the survey. Respondents identified a number of challenges in the development of medical leadership, and there was often perceived to be an engagement gap between medical leaders and doctors in clinical roles. While some progress has been made in the development of medical leadership in the NHS in England, much remains to be done to complete the journey that started with the Griffiths Report in 1983. We conclude that a greater degree of professionalism needs to be brought to bear in the development of medical leadership. This includes developing career structures to make it easier for doctors to take on leadership roles; providing training, development and support in management and leadership at different stages of doctors’ careers; and ensuring that pay and other rewards are commensurate with the responsibilities of medical leaders. The time commitment of medical leaders and the proportion of doctors in leadership roles both need to increase. The paper concludes considering the implications of these findings for other health systems. [ABSTRACT FROM PUBLISHER]

AimTo undertake a service evaluation of the NHS East of England Supporting Self-Care in General Practice programme.BackgroundThe number of people purported to live with long-term conditions continues to rise generating increasing policy emphasis on the importance of self-care. Previous work has highlighted barriers to implementing self-care interventions in general practice, including a lack of organisational approaches to providing self-care and limited engagement and training of healthcare professionals. In response to these barriers and policy drivers, NHS East of England Strategic Health Authority developed and commenced the Supporting Self-care in General Practice (SSCiGP) programme, which seeks to transform the relationships between people with long-term conditions and primary care practitioners.MethodsThis was a mixed methods study, carried out over two phases, which included interviews, survey work and practice-based case studies.ResultsThis paper focuses on findings related to clinician and practice level change. Clinicians reported changes in their perceptions and in consultation practices following attendance on the SSCiGP programme. These changes were linked to empathy and patient-centredness that mirrored what patients valued in interactions with clinicians. There were qualitative and descriptive differences, but no statistically significant differences between clinicians who had and had not attended the SSCiGP programme. Time was recognised as a significant barrier to implementing, and sustaining skills learnt from the SSCiGP programme.Greater impact at practice level could be achieved when there was whole practice commitment to values that underpinned the SSCiGP programme. There was evidence that such approaches are being incorporated to change practice systems and structures to better facilitate self-care, particularly in practices who were early programme adopters.ConclusionThis evaluation demonstrates that training around clinician change can be effective in shifting service delivery when sat within a cultural framework that genuinely situates patients at the centre of consultations and practice activity. [ABSTRACT FROM AUTHOR]

Background: Some local areas in England stopped have gluten‐free prescriptions for coeliac disease. An explanatory mixed‐methods study has investigated the impact of these changes. Methods: A cross‐sectional survey with 1697 participants was followed by 24 qualitative interviews. The survey included questions on the use of prescriptions and healthcare services, as well as the Coeliac Disease Assessment Questionnaire (CDAQ) to assess quality of life. The survey data were analysed by descriptive statistics, analysis of variance and regression analysis, and the interviews were analysed by thematic analysis. Findings from the interviews guided the survey analysis. Results: Dietary burden was significantly different between prescribing and nonprescribing areas, with little impact on other aspects of quality of life. Survey participants in nonprescribing areas who felt more impacted by the prescription changes reported a lower quality of life. Satisfaction with and use of services was lower in nonprescribing areas. Interviews indicated that, after initial frustrations, most people adapted to the changed prescription policy. However, there was a clear preference for gluten‐free prescriptions to be available, in particular for staple foods. Conclusions: The main quality of life impact was on Dietary burden. It is encouraging that most participants in the present study maintained a good quality of life. However, issues of worse experiences of care, lower follow‐up opportunities and inequity arose, and these should be taken into consideration in decisions on gluten‐free food prescriptions. The new guidelines for the National Health Service in England have retained prescriptions for bread and flour mixes, which is more limited than the range of staple foods preferred in the present study. [ABSTRACT FROM AUTHOR]

Background With the aim of decreasing immigration, the British government extended charging for healthcare in England for certain migrants in 2017. There is concern these policies amplify the barriers to healthcare already faced by asylum seekers and refugees (ASRs). Awareness has been shown to be fundamental to access. This article jointly explores (i) health care professionals' (HCPs) awareness of migrants' eligibility for healthcare, and (ii) ASRs' awareness of health services. Methods Mixed methods were used. Quantitative survey data explored HCPs' awareness of migrants' eligibility to healthcare after the extension of charging regulations. Qualitative data from semi-structured interviews with ASRs were analyzed thematically using Saurman's domains of awareness as a framework. Results In total 514 HCPs responded to the survey. Significant gaps in HCPs' awareness of definitions, entitlements and charging regulations were identified. 80% of HCP respondents were not confident defining the immigration categories upon which eligibility for care rests. Only a small minority (6%) reported both awareness and understanding of the charging regulations. In parallel, the 18 ASRs interviewed had poor awareness of their eligibility for free National Health Service care and suitability for particular services. This was compounded by language difficulties, social isolation, frequent asylum dispersal accommodation moves, and poverty. Conclusion This study identifies significant confusion amongst both HCP and ASR concerning eligibility and healthcare access. The consequent negative impact on health is concerning given the contemporary political climate, where eligibility for healthcare depends on immigration status. [ABSTRACT FROM AUTHOR]

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation. Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping. Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators. Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered. [ABSTRACT FROM AUTHOR]

Background: The past decade has seen significant, system-wide changes to the midwifery profession as a result of major reports. A recurring theme throughout is the importance of professional midwifery leadership at a local, regional and national level. Aims: To explore the profile of professional midwifery leadership in England following significant and system-wide changes to the midwifery profession over the past 10 years. Methods: Access to an online survey was forwarded to Directors of Midwifery and Heads of Midwifery in England to gain understanding of the profile of midwifery leadership at a local, provider level. One-to-one meetings were conducted with senior, executive NHS professionals and chief executives from the Royal College of Nursing and Royal College of Midwives, politicians and members of the House of Lords. Findings: Further recognition of midwifery as a separate profession is needed with due regard and formal authority afforded the profession at local, regional and national levels. Maternity services will benefit from employing a Director of Midwifery with direct access to the Trust Board. Conclusion: There is a need for the national, regional and local senior midwifery structures to be reviewed with consideration given to a Chief Midwife nationally; Directors of Midwifery regionally and in every provider Trust in England. [ABSTRACT FROM AUTHOR]

Aim This article offers nurse managers guidance on analysing, managing and addressing a potentially dissatisfied nursing workforce, focusing on three priority shortage specialties: emergency care, paediatrics and cardiology. The aim of the study was to explore to what extent registered nurses and healthcare assistants, referred to collectively here as 'nursing staff', are satisfied with teamworking opportunities, continuing professional development (CPD) opportunities and workplace autonomy. Method A survey questionnaire was developed to evaluate three derived determinants of nurse satisfaction: team working, CPD and autonomy. The NHS West Midlands region was the focus given that it is among the poorest performing regions outside London in filling nursing posts. Findings Overall, nursing staff respondents were satisfied with teamworking, CPD and autonomy, which challenges the perception that nurses in NHS England are dissatisfied with these satisfaction determinants. The findings give a complex picture of nurse satisfaction; for example a large minority of respondents were dissatisfied with their ability to carry out duties as they see fit. Conclusion When developing management systems to investigate, manage and enhance nurse satisfaction, nurse managers must recognise the complexity and subtleties of determining factors. This will increase as nursing becomes more specialised. Subsequently, nurse managers need to work closely with staff at higher education institutions and other professional agencies to commission appropriate professional development. [ABSTRACT FROM AUTHOR]

Aims and objectives: To report the findings from an evaluation of the impact of the Compassion in Practice Vision and Strategy (National Health Service England (NHSE), 2012) on nursing, midwifery and care staff. Background: The Compassion in Practice Vision and Strategy was a programme of work to highlight the importance of compassionate care following the Francis Report in 2013 into the deficits in care in an NHS Hospital Trust. It was launched by NHS England in 2012 at a time when fiscal cuts were introduced by the Department of Health in England. Design and setting: Mixed methods. Results: Inferential statistics were used to test whether there were significant differences between staff at different levels of seniority with regard to awareness and involvement in Compassion in Practice Vision and Strategy and their attitudes to it. Awareness and involvement of staff in Compassion in Practice Vision and Strategy were high amongst middle and senior management but limited at ward level. Staff involvement in Compassion in Practice Vision and Strategy was limited due to a lack of awareness. Ward level staff who were aware and involved, perceived a lack of support and communication from senior leadership to deliver the Compassion in Practice Vision and Strategy. Discussion: Results reveal professional anger, distress and resistance to the Compassion in Practice Vision and Strategy and a view of the programme as a top‐down initiative which did not sufficiently recognise structural constraints on nurses’ ability to deliver compassionate care. We discuss the implications of our findings for global nursing. Conclusion: Participants emphasised that compassion for patients is only sustainable where there is compassion for staff and many participants felt that they were not being treated with compassion. Relevance for clinical practice: National Health Service England should strongly affirm that nurses and midwives in general provide compassionate care. Trust leadership should provide support for ward level staff who deliver compassionate care in difficult circumstances. [ABSTRACT FROM AUTHOR]

Aims To understand issues around carer roles that affect carer involvement for people with intellectual disabilities in acute hospitals. Background There is evidence that a lack of effective carer involvement can lead to poorer health outcomes for people with intellectual disabilities, but there is a lack of insight into the reasons for poor carer involvement in acute hospitals. Design Mixed methods in six acute hospital trusts in England (2011-2013). Methods Electronic hospital staff survey ( n = 990), carer questionnaires ( n = 88), semi-structured interviews with hospital staff ( n = 68) and carers ( n = 37). Data were triangulated and analysed using a conceptual framework. Results There was strong support for carer involvement among hospital staff, and most carers indicated that they felt welcomed and supported. However, an investigation of negative experiences showed that there were discrepancies in the perspectives of hospital staff and carers on the scope of 'carer involvement'. An important contributory factor to the effectiveness of carer involvement was the degree to which staff understood the importance of carer expertise (rather than simply carer work) and welcomed it. Carers' contributions to basic nursing care tasks could be taken for granted by hospital staff, sometimes erroneously. Conclusion The roles and contributions of carers should be clarified on an individual basis by hospital staff. The authors propose a new model to support this clarification. Further research is needed to assess the suitability of the model for patients with intellectual disabilities and other vulnerable patient groups. [ABSTRACT FROM AUTHOR]

This article describes a study to ascertain what it is like to follow the processes in practice for prevention and management of pressure ulcers as one aspect of care among others. The participants in this study were bands 5 and 6 staff nurses and healthcare assistants (HCAs) (n=72) recruited from two acute and two primary NHS trusts. Data were gathered from open-ended questions via an online survey (n=61) and interviews (n=11). The interviews were transcribed and all the data were analysed by thematic analysis. The findings show that participants believe there has been a high-profile imposition of guidelines and policies by management during at least the past 18 months, resulting in perceived good outcomes in the form of fewer pressure ulcers generally and less fragmentation of care, particularly within primary care. However, a number of perceived obstacles to the implementation of recommended interventions remain, notably lack of time and lack of knowledge. [ABSTRACT FROM AUTHOR]

Objectives: To examine the skills and expertise required and used by non-clinical call-handlers doing telephone triage and assessment, supported by a computer decision support system (CDSS) in urgent and emergency care services. Methods: Comparative case study of three different English emergency and urgent care services. Data consisted of nearly 500 hours of non-participant observation, 61 semi-structured interviews with health service staff, documentary analysis, and a survey of 106 call-handlers. Results: Communication skills and 'allowing the CDSS to drive the assessment' are viewed by the CDSS developers and staff as key competencies for call-handling. Call-handlers demonstrated high levels of experience, skills and expertise in using the CDSS. These workers are often portrayed simply as 'trained users' of technology, but they used a broader set of skills including team work, flexibility and 'translation'. Call-handlers develop a 'pseudo-clinical' expertise and draw upon their experiential knowledge to bring the CDSS into everyday use. Conclusions: Clinical assessment and triage by non-clinical staff supported by a CDSS represents a major change in urgent and emergency care delivery, warranting a detailed examination of call-handlers' skills and expertise. We found that this work appears to have more in common with clinical work and expertise than with other call-centre work that it superficially resembles. Recognizing the range of skills call-handlers demonstrate and developing a better understanding of this should be incorporated into the training for, and management of, emergency and urgent care call-handling. [ABSTRACT FROM AUTHOR]

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting,then fostering a more inclusive and transparent process will be required. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the tensions faced in commissioning services for children's speech, language and communication needs and to identify variation in commissioning practice in response to these tensions. Methods: Quantitative and qualitative evidence from a review of speech, language and communication services in one English region, focused on three case studies. Results: The case studies reveal variation in practice in relation to commissioning tensions generated by: low incidence/high needs cases, blurred boundaries between health and education, multi-agency working, parental voice and service development. The introduction of commissioning and models of practice such as 'the commissioning cycle' has left huge variation between localities in levels and type of provision for these services. Conclusion: Large variation in commissioning practice is associated with commissioners' adoption of one of three models: a market model, an integrated model and a top-up model. [ABSTRACT FROM AUTHOR]

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 wellbeing 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. [ABSTRACT FROM AUTHOR]