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BackgroundTwo general practices close every week in the UK. Given the pressure on UK general practices, such closures are likely to persist. Yet little is known about the consequences. Closure refers to when a practice ceases to exist, merges, or is taken over.AimTo explore whether practice funding, list size, workforce composition, and quality change in surviving practices when surrounding general practices close.Design and settingA cross-sectional study of English general practices was undertaken, using data from 2016–2020.MethodThe exposure to closure for all practices existing on 31 March 2020 was estimated. This is the estimation proportion of a practice’s patient list that had been through a closure in the preceding 3 years, between 1 April 2016 and 3 March 2019. The interaction between the exposure to closure estimate and the outcome variables (list size, funding, workforce, and quality) was analysed through multiple linear regression, while controlling for confounders (age profile, deprivation, ethnic group, and rurality).ResultsA total of 694 (8.41%) practices closed. A 10% increase in exposure to closure resulted in 1925.6 (95% confidence interval [CI] = 1675.8 to 2175.4) more patients in the practice with £2.37 (95% CI = £4.22 to £0.51) less funding per patient. While numbers of all staff types increased, there were 86.9 (95% CI = 50.5 to 123.3), 4.3%, more patients per GP. Increases for other staff types were proportionate to increases in patients. Patient satisfaction with services declined across all domains. No significant difference in Quality and Outcomes Framework (QOF) scores was identified.ConclusionHigher exposure to closure led to larger practice sizes in remaining practices. Closure of practices changes workforce composition and reduces patient satisfaction with services.

The devolution of public services from central to local government can increase sensitivity to local population needs but might also reduce the expertise and resources available. Little evidence is available on the impact of devolution on population health. We evaluated the effect of devolution affecting health services and wider determinants of health on life expectancy in Greater Manchester, England.We estimated changes in life expectancy in Greater Manchester relative to a control group from the rest of England (excluding London), using a generalised synthetic control method. Using local district-level data collected between Jan 1, 2006 and Dec 31, 2019, we estimated the effect of devolution on the whole population and stratified by sex, district, income deprivation, and baseline life expectancy.After devolution, from November, 2014, life expectancy in Greater Manchester was 0·196 years (95% CI 0·182-0·210) higher than expected when compared with the synthetic control group with similar pre-devolution trends. Life expectancy was protected from the decline observed in comparable areas in the 2 years after devolution and increased in the longer term. Increases in life expectancy were observed in eight of ten local authorities, were larger among men than women (0·338 years [0·315-0·362] for men; 0·057 years [0·040-0·074] for women), and were larger in areas with high income deprivation (0·390 years [0·369-0·412]) and lower life expectancy before devolution (0·291 years [0·271-0·311]).Greater Manchester had better life expectancy than expected after devolution. The benefits of devolution were apparent in the areas with the highest income deprivation and lowest life expectancy, suggesting a narrowing of inequalities. Improvements were likely to be due to a coordinated devolution across sectors, affecting wider determinants of health and the organisation of care services.The Health Foundation and the National Institute for Health and Care Research.

BackgroundThe diversification of types of staff delivering primary care may affect professional, population, and system outcomes.AimTo estimate associations between workforce composition and outcomes.Design and settingCross-sectional analysis of 6210 GP practices from a range of geographical settings across England in 2019.MethodA multivariable regression analysis was undertaken, relating numbers of staff in four groups — GPs, nurses, healthcare professionals, and health associate professionals — to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions (subsample of practices), and costs to the NHS. Data were obtained from the GP Patient Survey 2019, Quality and Outcomes Framework, prescribing data, the Hospital Episode Statistics database, the NHS Payments to General Practice 2019/2020, and the Tenth National GP Worklife Survey 2019.ResultsHaving additional GPs was associated with higher levels of satisfaction for the GPs themselves and for patients, whereas additional staff of other types had opposite associations with these outcomes. Having additional nurses and health associate professionals was associated with lower costs per prescription but more prescribing activity than having additional staff from the other two groups. Having more GPs was associated with higher costs per prescription and lower use of narrow-spectrum antibiotics compared with the other staff groups. Except for health associate professionals, greater staff numbers were associated with more hospital activity.ConclusionProfessional, population, and system outcomes showed a variety of associations with primary care workforce composition. Having additional nurses was associated with lower quality in some aspects, and higher costs and activity. The association between additional healthcare professionals or health associate professionals and higher costs was less than that for additional GPs, but was also linked to lower patient and GP satisfaction.

Objective Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model – or ‘Vanguard’ – programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up. Methods We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation. Results A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models. Conclusions This programme is an example of the ‘scale and spread paradox’, in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

In this chapter we introduce the background and rationale for our historical review of community nursing services through the lens of health policy. We provide the research questions the review is based on and detail the topic themes used to structure our answers to these questions. We have considered policy relating to community nursing services over seven eras from 1948 to the present day and each subsequent chapter details this. A definition of community/district nursing used for the purposes of the review is provided, as well as an outline of the structure of the chapters and the book. Each chapter will follow a consistent format: Historical context The role and function of community/district nursing services The management of community/district nursing services and the population covered Financing community/district nursing services Summary

In this chapter, we detail the first major re-organisation of the NHS since its inception and the consequences for community nursing. The 1974 wholesale re-organisation was born out of frustrations with the management and fragmentation of services resulting from the tripartite system. Services were bought together in a unitary model, centrally controlled but geographically organised. Local Authorities (LAs) were divested of many of their healthcare responsibilities including community nursing, which was transferred under the responsibility of newly created Area Health Authorities (AHAs). There was optimism that bringing community nursing under the NHS umbrella would foster a new era of co-ordinated working between all disciplines in the system, such as hospital nursing. Unfortunately, many of these intended aspirations were not realised despite the importance of the service to policy agendas emphasising integration, out-of-hospital care and prevention of ill health. In terms of managing and financing the district nursing service, this was not simplified by the re-organisation and population coverage continued as a mix of geographical and attachment to GP services. We conclude this chapter by emphasising the increasing demand for community and district nursing services. It became apparent in this era that the re-organisation did not bring any significant improvements and thus the attention shifted again towards organisational and management solutions to the NHS’ problems.

This chapter centres on the publishing of the NHS Long Term Plan in 2019 and subsequent revised Health and Social Care Act (2022), both of which focus on integrated, out-of-hospital approaches to health service delivery. The creation of a layered system across geographical levels is advocated, with nested levels of ‘place’ and ‘neighbourhood’ intended to be the building blocks of Integrated Care Systems (ICS), which replaced CCGs in July 2022. We introduce the concept of newly created, ‘neighbourhood level’, Primary Care Networks (PCNs) of general practices and how district nurses fit into them, especially with regard to their organisation around geographical versus GP registered lists. Whilst not explicitly mentioned in the H&SC Act, it is clear that the Act situates community-based services as essential in the context of the desire to reduce the amount of hospital care, which has implications for district nursing services in particular. This mode of care delivery will require multi-disciplinary team working across all levels of the new system whereby community nurses will be required to liaise and co-ordinate with primary and social care to deliver services. Continuance of case management approaches for patients with complex needs and lack of funding in the social care system, means that we discuss in this chapter, the further strain on already pressured community nursing teams.

The National Health Service and Community Care Act 1990, set in motion by the publication of the 1989 White Papers—Working for Patients and Caring for People, saw an intense time of policy change which would profoundly impact community and district nursing services. These papers ushered in the introduction of the internal market with purchaser/provider split between commissioners and providers of services, aiming for better services, better patient choice and to reduce costs. This chapter focuses on how the NHS was re-structured to facilitate this quasi-market organisation with Health Authorities (HAs), once pivotal, replaced by Primary Care Groups (PCGs) at the end of the decade. We document here the impact of these changes on the district nursing service as well as bringing to the fore that it was a service in crisis and in need of attention. Heavy caseloads coupled with a diminishing workforce led to a review of the grading system and an increasing use of ‘skill-mix’. We also highlight that aligned with internal marketisation ideals, funding of community services was based on a crude count of average number of contacts rather than based on the complexities of the role. As ever, there was a need for district nurses to ‘deliver more for less’ (Audit Commission, 1999, p. 94) at the end of the era.

In this final chapter of the book, we return to our original research questions and draw together our findings, looking across the eras to illustrate how the policy changes of the past have defined the services of today and the future. We show how, over time, there has been a consistent pattern in policy by which community nursing services are rarely the focus of policy. Rather, changes have occurred in policy which have had a knock-on effect on Community Health Services (CHS), and these effects have often been to their detriment. In the conclusion, we offer observations on the incoming policy changes in 2022 (H&CA, 2022) and suggestions for future research. Proposals for the development of Integrated Care Systems (ICS) offer both opportunities and threats to the provision of community nursing/health services—the former from more investment or the latter from being dominated by larger acute services. Our main concern is there is a danger that the voice and needs of CHS will yet again remain unheard and un-regarded.

Taking the first era from the inception of the NHS through to 1974, this chapter documents the establishment of the service as a home nursing service. Known as the ‘tripartite era’ because of the way provision of health services were divided between three types of bodies—Local Authorities (LA), Executive Councils of the Ministry of Health and Hospital Boards—this era would see a split enshrined between LA-provided community nursing services and medical services provided by the others. This split has been a feature of the NHS ever since, despite successive unifying re-organisations of the health service, and has come to define the way community nursing is perceived by policy apparent in this review. In line with the format of the chapters, we start to look at the role and function of district nurses (DNs) and begin to see how the role was focused on home care for the sick, management of infectious diseases and supporting doctors. We also begin to examine how DNs were managed and paid for and identify the enduring tensions in how they are organised—either geographically or attached to GP practices. We conclude this chapter with a brief paragraph summing up that for this era the role of district nurse services, despite becoming a national requirement, is rarely fully set out in policy. In other words, the district nursing service was largely invisible in policy terms.

The new millennium saw the publication of The NHS Plan in 2000, which bought a welcome focus to community health services (CHS) and the role of community nursing. We outline the proposals contained in the plan which furthered the quasi-marketisation of the NHS and increased commissioning of health care at the local level of Primary Care Trusts (PCTs)—replacing Health Authorities (HAs) and Primary Care Groups (PCGs). A further review by Lord Darzi and subsequent policy, Transforming Community Services: Enabling new patterns of provision (DoH, 2009) instigated the separation of commissioning/provision and laid out timetables for how PCTs were to do this. The long held roles of the district nursing service continues in this era, although not always clearly defined, understood or acknowledged and policy attempts to expand their remit feature heavily. This included more clinical tasks as well as focusing on such things as public health/health protection and promotion programmes that improve health and reduce inequalities. This chapter also describes the uncertainty for frontline nurses that the Transforming Community Services (TCS) brought in terms of who their employer would be or what management arrangements they would work under given the establishment of some standalone Trusts, some third sector and some combined acute/community Trusts. The aims of the TCS programme were bold but in reality achieved little by the end of the era.

A change of government in 2010 brought fresh NHS reforms and a new Health and Social Care Act (HSCA, 2012). Both, along with the 2014, Five Year Forward View (NHSE) set the tone for this Chapter. We discuss how the continued emphasis on competition between providers, and the introduction of Clinical Commissioning Groups (CCGs) which replaced Primary Care Trusts (PCTs) as commissioners of community services, impacted on community nursing service management and delivery. Policy shifted in favour of a more co-operative approach to service provision and familiar agendas were set out for keeping people out of hospital with reform based around integration between health care sectors and between health and social care services. There was little change on the ground for district nurses in this era despite increasing emphasis on integrated care, collaborative, cross-sector working (i.e. with LA social care) and multi-disciplinary team management of complex patients. The HSCA 2012 began to unravel almost as soon as it was enacted, with the emphasis on competition undermined by the Five Year Forward View shift towards integration between sectors as a dominant organising principle. Community Health Services (CHS) were, to some extent, protected from the fragmentation associated with the Act, and in terms of district nursing practice, this era generated little change with patterns of service provision remaining very much as they were following the upheaval generated by the Transforming Community Services agenda.

This was another period of churn for the NHS. First, the service endured another restructuring exercise, reducing hierarchical layers to a less rigid bureaucratic structure. Area Health Authorities (AHAs) were abolished in 1982 and replaced by 192 District Health Authorities (DHAs). Second, there was a move away from ‘consensus’ style management towards ‘general management’ following the publication of the influential Griffiths Report in 1983. This marked an important phase in the NHS in which a clearly defined management function was implemented to improve efficiency, planning and accountability but bought shifting sands to the way community nursing services were managed. A review of community nursing services in a similar vein, The Cumberlege Report (1986), also proved significant. We focus on the recommendations of this report for improving the role and function of district nursing services and their geographical deployment to strengthen the concept of a localised, neighbourhood nursing structure. Whilst this was a period of change in terms of the organisation and management of Community Health Services and indeed the NHS as a whole, the core role of community or district nurses remained as one of care in the community but with an emphasis on greater multi-disciplinary team working.

PurposeThe article aims to argue that the concept of “distributed leadership” lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the “Strategic Action Field Framework” (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar.Design/methodology/approachUsing the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019.FindingsWhile literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting.Originality/valueThe SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of “social skills” required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

Background General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment. Limitations These findings may reflect turbulence during a period of rapid skill mix change in general practice. The current policy of employing staff through primary care networks is likely to accelerate workforce change and generate additional challenges. Conclusions Skill mix implementation is challenging because of the inherent complexity of general practice caseloads; it is associated with a mix of positive and negative outcome measures. Future work Findings from this study will inform future funding applications for projects that seek to examine the nature and impact of evolving multiprofessional teams in primary care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

Chapter 4 looks at the evidence about clinical engagement in primary care-led commissioning. Extending and strengthening clinical leadership was one of the key elements of the HSCA12. However, this idea was not new, and this chapter reviews the evidence on the role of clinicians in primary care-led commissioning and how this has contributed to the delivery of healthcare services since the early 1990s. It examines the nature of clinical engagement/involvement in the various primary care-led commissioning models that have been introduced into the NHS. Drawing on a review of the literature and our research on Clinical Commissioning Groups the chapter shows how the extent of clinical engagement has varied between the various schemes. GP commissioners have historically been more successful in influencing the work done by GP practices than in making broader changes to services provided by secondary care. The chapter goes on to explore the claims made both by those involved and in official documents about how greater involvement of clinicians in CCGs – and in particular GPs – will enhance commissioning practice. We test this against evidence from our study of CCGs, showing how the engagement and involvement of GPs requires careful attention to detail. Using a realist approach to evaluation, we highlight the contexts and mechanisms associated with successful – and unsuccessful – GP involvement in commissioning.

BackgroundIn recent years, UK health policy makers have responded to a GP shortage by introducing measures to support increased healthcare delivery by practitioners from a wider range of backgrounds.AimTo ascertain the composition of the primary care workforce in England at a time when policy changes affecting deployment of different practitioner types are being introduced.Design and settingThis study was a comparative analysis of workforce data reported to NHS Digital by GP practices in England.MethodStatistics are reported using practice-level data from the NHS Digital June 2019 data extract. Because of the role played by Health Education England (HEE) in training and increasing the skills of a healthcare workforce that meets the needs of each region, the analysis compares average workforce composition across the 13 HEE regions in EnglandResultsThe workforce participation in terms of full-time equivalent of each staff group across HEE regions demonstrates regional variation. Differences persist when expressed as mean full-time equivalent per thousand patients. Despite policy changes, most workers are employed in long-established primary care roles, with only a small proportion of newer types of practitioner, such as pharmacists, paramedics, physiotherapists, and physician associates.ConclusionThis study provides analysis of a more detailed and complete primary care workforce dataset than has previously been available in England. In describing the workforce composition at this time, the study provides a foundation for future comparative analyses of changing practitioner deployment before the introduction of primary care networks, and for evaluating outcomes and costs that may be associated with these changes.

Research has demonstrated that pilots contain multiple shifting purposes, not all of which relate to simple policy testing or refinement. Judging the success of policy pilots is therefore complex, requiring more than a simple judgement against declared goals. Marsh and McConnell provide a framework against which policy success can be judged, distinguishing programme success from process and political success. We adapt Boven's modification of this framework and apply it to policy pilots, arguing that pilot process, outcomes and longer term effects can all be judged in both programme and political terms. We test this new framework in a pilot programme in the English National Health Service, the Vanguard programme, showing how consideration of these different aspects of success sheds light on the programme and its aftermath. We consider the implications of the framework for the comprehensive and multi-faceted evaluation of policy pilots.

Introduction: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. Description: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration. The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots’ objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. Discussion: There was little stable or shared understanding of what ‘integrated care’ meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. Conclusion: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

BackgroundA 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme.ObjectivesTo conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme.MethodsSemistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews.ResultsParticipants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas.ConclusionPractices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.

ObjectiveTo quantify general practitioners’ (GPs’) turnover in England between 2007 and 2019, describe trends over time, regional differences and associations with social deprivation or other practice characteristics.DesignA retrospective study of annual cross-sectional data.SettingAll general practices in England (8085 in 2007, 6598 in 2019).MethodsWe calculated turnover rates, defined as the proportion of GPs leaving a practice. Rates and their median, 25th and 75th percentiles were calculated by year and region. The proportion of practices with persistent high turnover (>10%) over consecutive years were also calculated. A negative binomial regression model assessed the association between turnover and social deprivation or other practice characteristics.ResultsTurnover rates increased over time. The 75th percentile in 2009 was 11%, but increased to 14% in 2019. The highest turnover rate was observed in 2013–2014, corresponding to the 75th percentile of 18.2%. Over time, regions experienced increases in turnover rates, although it varied across English regions. The proportion of practices with high (10% to 40%) turnover within a year almost doubled from 14% in 2009 to 27% in 2019. A rise in the number of practices with persistent high turnover (>10%) for at least three consecutive years was also observed, from 2.7% (2.3%–3.1%) in 2007 to 6.3% (5.7%–6.9%) in 2017. The statistical analyses revealed that practice-area deprivation was moderately associated with turnover rate, with practices in the most deprived area having higher turnover rates compared with practices in the least deprived areas (incidence rate ratios 1.09; 95% CI 1.06 to 1.13).ConclusionsGP turnover has increased in the last decade nationally, with regional variability. Greater attention to GP turnover is needed, in the most deprived areas in particular, where GPs often need to deal with more complex health needs. There is a large cost associated with GP turnover and practices with very high persistent turnover need to be further researched, and the causes behind this identified, to allow support strategies and policies to be developed.

This article develops an analysis of population-level priority setting informed by Bevir's decentred theory of governance and drawing on a qualitative study of priority setting for service improvement conducted in the complex multi-layered governance context of English primary care. We show how powerful actors, operating at the meso-level, utilize pluralistic and contradictory elements of complex governance networks to discursively construct, legitimize and enact service improvement priorities. Our analysis highlights the role of situated agency in integrating top-down, bottom-up and horizontal influences on priority setting, which leads to variation in local priorities despite the continuous presence of strong hierarchical influences.

BackgroundGood access to primary care is an important determinant of population health. While the academic literature on access to care emphasises its complexity, policies aimed at improving access to general practice in the UK have tended to focus on measurable aspects, such as timeliness or number of appointments.AimTo fill the gap between the complex understanding of primary care access in the literature and the narrow definition of access assumed in UK policies.Design and settingQualitative, community-based participatory case study within the geographic footprint of a clinical commissioning group in the north west of England. Data collection took place from October 2015 to October 2016. Purposive sampling and snowball approaches were used to achieve maximum variation among service users and providers across general practice settings.MethodLevesque et al’s conceptual framework of patient-centred access was applied and the study used multiple qualitative methods (interviews, focus groups, and observation). Analysis was ongoing, iterative, inductive, and abductive with the theory.ResultsThe comprehensiveness of Levesque et al’s access theory resonated with diverse participant experiences. However, while its strength was to highlight the importance of people’s abilities to access care, this study’s data suggest equal importance of healthcare workforce abilities to make care accessible. Thus, the authors present a definition of access as the ‘human fit’ between the needs and abilities of people in the population and the abilities and capacity of people in the healthcare workforce, and provide a modified conceptual framework reflecting these insights.ConclusionAn understanding of access as ‘human fit’ has the potential to address longstanding problems of access within general practice, focusing attention on the need for staff training and support, and emphasising the importance of continuity of care.

Population health management is an increasingly popular concept in health systems. Driven by growth in ‘big data’, the approach uses aggregated data to identify and manage the health of those deemed ‘at risk’. We use the UK’s response to the COVID-19 pandemic as a lens to critically examine this approach to improving population health, using the policy of ‘shielding’ those at high risk of harm as an exemplar. Firstly, we explore the policy as an example of categorisation, showing that criteria used to identify high-risk population ‘segments’ are never wholly objective, arising out of negotiations taking account of economic, political, or social issues, with the categorization of individuals as in/out of the high-risk group always approximate. Secondly, we consider the construction of risk and demonstrate that focusing on biomedical data brackets out societal factors driving individual risks including deprivation, racial discrimination, and employment status. Finally, we highlight how this framing of COVID-19-associated risk as a biomedical issue leads to a neoliberal focus upon individual rather than societal risk-mitigation approaches. We argue that population health management should be married with traditional public health advocacy and campaigning, digging beneath identified disparities to expose and interrogate the structural factors at work.

ObjectivesThe UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced.Design and settingComparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation.Participants2048 GPs in Scotland and 879 GPs in England.Main outcome measuresFour intentions to reduce work participation (5-point scales: 1=‘none’, 5=‘high’): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1=‘extremely dissatisfied’, 7=‘extremely satisfied’); job stressors (5-point-scale: 1=‘no pressure’, 5=‘high pressure); positive and negative job attributes (5-point scales: 1=‘strongly disagree’, 5=‘strongly agree’).ResultsCompared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=−0.52; 95% CI −0.64 to −0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=−0.32; 95% CI −0.42 to −0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=−0.37; 95% CI −0.47 to −0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=−0.2; 95% CI −0.28 to −0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes.ConclusionFollowing the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.

BackgroundThe expansion of the primary care workforce by employing a varied range of practitioners (‘skill mix’) is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans.AimTo identify key motivating factors behind practice workforce decisions and their future workforce plans.MethodAn online questionnaire was sent to practice managers in England. Data collection is ongoing; however, 1000 practices have responded to the survey so far. The questionnaire was composed of questions related to current workforce, motivating factors behind employment decisions, planned future workforce changes, financial assistance with employing staff (for example, HEE or CCG funding) and ideal workforce.ResultsEarly results indicate that practices that have employed physician associates have done so to increase appointment availability (78% of practices) and release GP time (68%). Sixty-six per cent of practices who have employed pharmacists have received some form of financial assistance with 21% of practices still receiving assistance. When asked to construct an ideal workforce, ‘new’ roles accounted for 20% of that workforce on average, which is a significantly larger proportion than those roles currently account for.ConclusionAlthough data collection and analysis are ongoing, the results of the survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles such as pharmacists, PAs and paramedics.

Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread. We suggest that future programmes for large-scale policy implementation initiatives could be crafted differently to take account of the environment of implementation and render ambitions more realistic. Rather than aiming to create a set of definite products and templates, it may be that a set of principles for design and implementation should be developed and spread.

Background With innovation in service delivery increasingly viewed as crucial to the long-term sustainability of health systems, NHS England launched an ambitious new model of care (Vanguard) programme in 2015. Supported by a £350 million transformation fund, 50 Vanguard sites were to act as pilots for innovation in service delivery, to move quickly to change the way that services were delivered, breaking down barriers between sectors and improving the coordination and delivery of care. Methods As part of a national evaluation of the Vanguard programme, we conducted an evidence synthesis to assess the nature and quality of locally commissioned evaluations. With access to a secure, online hub used by the Vanguard and other integrated care initiatives, two researchers retrieved any documents from a locally commissioned evaluation for inclusion. All identified documents were downloaded and logged, and details of the evaluators, questions, methodological approaches and limitations in design and/or reporting were extracted. As included evaluations varied in nature and type, a narrative synthesis was undertaken. Results We identified a total of 115 separate reports relating to the locally commissioned evaluations. Five prominent issues relating to evaluation conduct were identified across included reports: use of logic models, number and type of evaluation questions posed, data sharing and information governance, methodological challenges and evaluation reporting in general. A combination of resource, data and time constraints means that evaluations often attempted to but did not fully address the wide range of questions posed by individual Vanguards. Conclusions Significant investment was made in independent local evaluations of the Vanguard programme by NHS England. This synthesis represents the only comprehensive attempt to capture methodological learning and may serve as a key resource for researchers and policy-makers seeking to understand investigating large-scale system change, both within the NHS and internationally. PROSPERO (Registration number: CRD42017069282).

Chapter 2 provides the context, setting out the organisation and governance of commissioning in the NHS. It includes a short summary of the architecture of commissioning pre-Health and Social Care Act (HSCA12), and highlights the important changes which were brought about by the Act, including the abolition of Primary Care Trusts and Strategic Health Authorities, the establishment of Clinical Commissioning Groups (CCGs), the creation of NHS England, transfer of commissioning responsibilities to different bodies (e.g. public health) and the setting up of local Health and Wellbeing Boards. The chapter also highlights the programme theories underlying the HSCA12, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning.

Chapter 3 deals with the development and early operation of Clinical Commissioning Groups (CCGs) of GPs. Building upon the context set out in chapter 2, we examine the factors affecting early CCG development, highlighting the complexity of their governance structures, approaches taken to engaging with their members and the development of external relationships with a wide range of new bodies. We found an explicitly ‘bottom up’ approach to policy implementation, with CCGs given considerable lee-way in developing their structures and processes. As a result, the history of previous commissioning structures and arrangements played an important role in the development of each CCG, as did the approach taken by local leaders and by the PCT/ developing NHS England local team. Engagement with local bodies such as Health and Wellbeing Boards and Local Authorities were also significantly affected by local history and geography. We found that the approach taken by NHS England to CCG development, with early freedom to develop as they chose increasingly curtailed by more prescriptive guidance and a complex assurance regime, led to some frustrations for those involved.