The majority of interviews were held face-to-face, with three being conducted by telephone at the request of respondents. Respondents were asked to present their own personal experiences and reflections, in addition to official organisational policy. Researchers’ reflections suggested that in most cases respondents were willing to express critical as well as positive perspectives on their experience of commissioning processes and activities. The following section first presents a brief overview of participants’ reflections on progress towards tackling health inequalities during the PCT era, followed by their views on future prospects. These findings are organised into three broad themes: opportunities and risks for the future; skills and competencies; and partnerships and engagement. Each section begins by highlighting the positive opportunities that respondents noted, and then considers any challenges and risks that they foresaw.
Past progress on commissioning to reduce health inequalities
Respondents generally felt that there had been pockets of good practice in commissioning to reduce health inequalities. These tended to occur where a pressing need had been identified, or where services and contracts were smaller and less dominated by existing block contracts, and therefore easier to change. When asked if commissioning had a significant influence on services, one respondent replied:
“It depends on whether you are commissioning from a blank sheet or commissioning an existing service. They’re quite different scenarios… a lot of services which were never specified, chugged along… And then there have been new services where they have decided to take the money out and try it another way through open tender” - Public Health Consultant
A common theme was that it is easier to inject attention to health inequalities when the commissioning task involves a new service, rather than the redesign of an existing one, and when new funding was available, this had provided opportunities to deliver new services and new providers through open tender.
Where circumstances allowed, a good number of respondents still felt that commissioning can be an important tool for service improvement to address inequalities.
“The real lever for change lies within commissioning” - PCT manager
“We are pretty effective at understanding what needs to change about services, redesigning and being able to commission” - Senior PCT manager
However, with another NHS restructuring being enacted, there was widespread recognition of the risk to this progress:
“Every time we’ve had a change of gear or direction in terms of the commissioning agenda, the sophistication that had been reached gets lost; everybody goes back to the beginning” - Public Health Observatory manager
There was a general feeling that commissioning had, over time, improved and that PCTs had become more skilled over the last decade at enacting commissioning, including around inequalities. Many PCT commissioners and other respondents expressed concern that this progress could be wasted as a result of reorganisation:
“I’m really nervous about it and I think good practice might be lost” - Third sector manager
Most respondents agreed that the PCT commissioning era had failed to deliver significant progress towards reduced health inequalities, and many reiterated the shortcomings documented in the published literature already highlighted above.
Several respondents highlighted the poor track record of PCTs in shifting resources out of secondary care and into the types of primary care and public health interventions felt to be capable of achieving a significant impact on health inequalities. Interviewees referred to the predominance of “transactional” commissioning work (that is the maintenance of existing contracts) rather than “transformational” action that they felt was required to make any real progress. As such, respondents usually felt that the bulk of commissioning activity was tied up in the momentum of historical contracts, with little resource left for innovative redesign:
“The momentum of the historical contracts has meant… a lot of what the commissioners are doing is almost working at the margins; where you’ve got extra resources you can have a discussion about how they’re best deployed, obviously most of the resources is in a basic set of core contracts” - Public Health Observatory manager
Respondents’ views also highlighted a perception that responsibility for the health inequalities agenda was seen primarily as a function of Public Health roles rather than part-and-parcel of core healthcare commissioning work, even where PCTs had adopted explicit strategic priorities relating to inequalities.
“Meeting health inequalities is part of the bread and butter of Public Health” - Public Health Observatory manager
“In terms of bringing evidence to the table around need… that is more of a Public Health role” - Public Health commissioner
While respondents recognised that many organisations had policy statements and process documents reflecting an apparent commitment to addressing inequalities, they felt these did little to influence action. Some respondents also accused PCTs of tokenism in relation to health inequalities, particularly when the focus was on inequalities experienced by ‘protected groups’ such as minority ethnic people. One respondent noted how PCTs often had one or two project examples that would be widely cited as evidence of their work on inequalities; what he referred to as their ‘get-out-of-jail-free-card’ [DH project manager].
“We do these sort of cursory tick box exercises, which frankly are not helpful, because we do them, then we put them in a drawer and forget all about them” - PCT commissioner
“There is a part of the world of equality and diversity, equality impact assessments and some of the hoops which you have to be seen to be going through to demonstrate that you are competent and aware… for me that feels slightly tokenistic” - PCT commissioner
Many respondents also highlighted the failure of Joint Strategic Needs Assessments - an exercise that was supposed to be conducted between PCTs and Local Authorities to identify health and wellbeing needs, review provision and set priorities for investment - to really have an influence on mainstream commissioning action in relation to inequalities. While there was awareness of the intended function of these documents/exercises, there was general agreement that they were not used systematically and had little impact on commissioning practice.
“Whether people take full ownership of the Joint Strategic Needs Assessment, and whether every single commissioner in this district uses it - I would question that” - PCT Public Health commissioner
More generally, respondents felt that the use of data and evidence about local health needs and inequalities was very variable in commissioning, and that there was a particular lack of data availability and use relating to specific axes of inequality:
“Even the evidence that we have isn’t being used in order to inform how we commission, how we target, how we provide particular services” - Public Health Observatory manager
“The health equity audit has been very much focused on either geography, and even that’s a proxy for social class really… and some of the other dimensions like ethnicity have been underplayed” - Public Health Observatory manager
Opportunities, challenges and risks for the future
In terms of the prospects for addressing inequalities in the future, some respondents felt that local levers, in particular the Joint Strategic Needs Assessment and Health & Wellbeing Strategies, could significantly shape CCG commissioning actions in the new era:
“The Health & Wellbeing Board are a key lever for some of this work as well, and the JSNA’s are a critical tool. Then Local Authorities will also have other tools in terms of they have done quite a lot of work on different wards and the needs of those wards - they’ve done lots of work on different interest groups, they’ve had their own community and neighbourhood strategies and all sorts” - SHA Equality and Diversity Lead
Indeed, there was a degree of optimism that the new local structures and processes, especially those based in Local Authorities, could improve accountability to the general public and therefore increase attention to inequalities:
“Local government… their track record on ensuring equality in things like housing, you know, and education and so forth, they’ve been much less squeamish about collecting data and using it” - Third sector manager
Nonetheless, many respondents expressed doubts about the likely representation of community interests on the emergent Health & Wellbeing Boards and whether in practice they would have the teeth to hold CCGs to account.
“What I don’t know is how much the health and wellbeing boards and their local strategies will be able to influence the GP commissioning groups, you know, who may be focused on the patients that they see most often” - Public Health Observatory manager
Future commitment to the health inequalities agenda
Across the board respondents felt there was a real danger that recognition and commitment to health inequalities would be weakened in the new arrangements. Three key concerns were highlighted: (i) weakened directives from central government; (ii) clinical commissioners’ lack of engagement with a population perspective; and (iii) reduced public health input into health services commissioning.
While some respondents felt that CCG-led commissioning could be positive in localities where GPs had been able to see the impact of inequalities in their local population (and were therefore able to address this directly), even where GPs were already committed to this agenda, respondents felt that the current emphasis on localism and the “hands off” approach by national government would result in piecemeal attention to health inequalities that relied on enthusiastic individuals to stimulate activity:
“Some of the consortia that we’re dealing with, I think will take this [health inequalities] very seriously, and probably embed it in their work, but I think that’s more spontaneous, from their own drive” - Third sector manager
Respondents worried that weakened directives from central government on the importance of addressing health inequalities would mean that other priorities - particularly financial probity and efficiency - would likely dominate CCG work.
“I fear that we may have a period of about eighteen months where that [health inequalities work] is put on hold because there is so much else for folk to juggle with” - PCT information manager
“If their main focus is on financial balance, a lot of the work that they’ll be doing will be precisely that, commissioning to try and manage the finances, and will not be commissioning to move the community in a direction for better public health necessarily” - General Practitioner
Across local and national interviews, respondents felt that GPs did not, by and large, have an awareness of inequalities in service access, experience and outcomes. Respondents speculated that GP commissioners would tend to draw on their experiences in the consultation room, and that this would undermine attention to under-served groups.
“GPs look at the patient in front of them or on their list, and not at the people that don’t access them, or are not coming through the door” - Third sector manager
“Most of general practice is not engaged in the inequalities agenda at all… Most GPs don’t have skills and interest in this area” - Third sector manager
“What they’re being given is a huge task that they didn’t necessarily ask for, nor are they necessarily equipped to undertake because most of them aren’t involved at a strategic level; they’re sitting every day in their surgeries practising medicine” - Department of Health manager
Thus, while GPs were felt to have strong clinical skills and experience with patient care pathways at an individual level, respondents felt that, as CCG members, GPs might have a poor understanding of the importance of taking a population perspective on inequalities.
“There are lots of strengths to [CCG commissioning]. I hope that it is much more people-centred, but the people [i.e. service users] that it will be centred on are those who are engaged with primary care practices, and there is a risk that those people who have greatest difficulty in engaging will be the ones who miss out” - PCT information manager
“[GPs are] too close to the coal face, so that they lack the bird’s-eye vision of the whole picture” - General Practitioner
Some respondents worried that the move of public health away from the healthcare commissioning function to Local Authorities would further dilute consideration of action on health inequalities by the new CCGs, particularly since they might be less likely to draw on public health intelligence data.
“I think the PCTs, warts and all, they did have a sort of area based view - ‘This the area that I’m responsible for, this population’. They had the overview across all health care… I think they covered public health inequalities and NHS care… I think this whole divide between public health and… [healthcare commissioning], it’s divisive, it mitigates against…” - Third sector manager
Respondents also worried about how CCGs could be encouraged to commit resources to prevention and health promotion, without such work being labelled as public health and therefore beyond their remit.
Skills and competencies to deliver on health inequalities
Respondents were worried that CCG commissioners would overlook the need for effective community engagement and were not generally well equipped to deal with the politics and emotions that are inevitably faced in the commissioning role, suggesting that they would need “a lot of hand holding” - PCT Public Health commissioner.
There were also general concerns about the loss of good practice and expertise in health inequalities work, particularly since some of the key skills, such as patient and public involvement (PPI) and equality and diversity (E&D), were seen to have been shed from PCTs early on during re-structuring in many places. These skills and the networks that had been built up with communities by engagement and equality officers would be lost from many commissioning support organisations, and CCGs would have to start again from scratch, mirroring the loss of connectivity and effective working that occurred as a result of earlier reorganisations.
Meanwhile, respondents felt that the small size of CCGs would inevitably mean that these would include a narrower range of skills than currently embedded in PCTs and that the likely reliance on ad hoc, consultancy inputs was undesirable:
“No doubt many [CCGs] will subcontract, they may contract to private companies. It depends on what skills and interest reside there, what focus, what priority those contractors will put on addressing inequalities… It’s very uncertain I think” - Third sector manager
In addition to voicing concerns regarding the steep learning curve facing the new commissioners, several respondents also bemoaned the loss of national support structures and regional networks that had in the past been important mechanisms for enhancing skills, competence and knowledge on how to address health inequalities.
“The challenge for us going forward is to keep some of that network going, because the regional structures have gone. And also some of their national structures have gone. So if we change tack slightly, the National Mental Health Development Unit, if I had wanted information on, specific services or evidence of effectiveness around ethnicity, it might have been one of the places I started looking for evidence, or even picking up the phone. Now that was disbanded” - Third sector manager
Partnerships, influence and engagement
Closely related to worries about CCG skills mentioned above, it was notable that many respondents explicitly discussed the requirement for the new commissioners to be able to work in partnership, engage and exert the necessary influence to bring about action on inequalities.
Alongside the significance attached to professional networks, most respondents highlighted the importance of a broader spectrum of partnerships and engagement. On the positive side, some respondents felt that CCGs would be able to make use of their peer networks and clinical knowledge to bring about improvements in primary care access and quality, and would exploit their shared background to gain access, influence and cooperation where PCT managers had often struggled in the past.
“I think if you come from primary care, so again it’s almost like coming from within, and you’re trying to sell the package back to your peers. There’s much more of a buy-in there, really” - General Practitioner
However, opinions were mixed as to whether such influence would extend to the hospital trusts, the major consumer of resources, with some respondents feeling the GP commissioners would be completely out of their depth in negotiations concerning the hundreds of contracts PCTs currently held,
“I keep describing it as is an ecosystem and unless you understand the whole or the chunks of it you’ll miss out” - Public Health manager
Several respondents, who perhaps saw GPs as obstacles to health inequalities work in the past, felt it was a positive development to have GPs properly engaged in the commissioning process, and felt that this would help to ensure greater cooperation in working towards addressing inequalities, since primary care has such a key role to play.
“It’s a very powerful opportunity. Now in addition to being the main providers, they’re the commissioners, so it’s all come together” - Third sector manager
Similarly, some local third sector respondents saw potential benefits to future working with GPs as commissioners and welcomed the possibility that this new role might connect them more effectively with the communities they serve. There were also signs across all respondent groups that at least some GPs are aware of their need to learn from, and engage with, wider partners, including members of local communities, if they are to undertake their new role effectively.
Some respondents also highlighted positive opportunities for new partnership work in pursuit of reduced health inequalities. For instance, the potential for greater integration of knowledge and data on local communities, stronger JSNAs and better understanding of needs, was noted with the move of public health to Local Authorities. In addition, new structures, particularly the HWBB, created the possibility of new opportunities for representation.
However, despite these positive views, the general feeling was that restructuring presented significant risks to partnership working. Several respondents emphasised that partnerships between organisations are fundamentally based on personal relationships and that these take time to establish.
“If you’ve got that longer standing relationship you can also have a more full and frank discussion and not skirt around some of the issues and take forever and a day… it takes a long time doesn’t it [to develop those relationships] and time is money” - Public Health manager
Several respondents also noted that GPs were, by-and-large, not used to working in partnership or taking on the statutory duties that CCGs will be charged with. Respondents particularly noted their lack of understanding of how Local Authorities operate and the consequent risk that their links with public health would not be functional in terms of balancing a range of priorities.
“People recall fund-holding as something where they had a lot of autonomy, a lot of control. Commissioning has moved on in leaps and bounds in different ways since then, and it’s a very different variable beast, where you’re having to deliver national things which you may not agree with, but you’re the conduit for it, and at the same time you’re responding to your local community, and you’re trying to balance the two, because sometimes they conflict” - General Practitioner
Both GPs and people working in PCTs noted that relationships between the two groups were not always cordial. Caution was also expressed by both GPs and other respondents that some GPs would take the opportunity for independence from the PCTs to commission in completely different ways, and in so doing ignore years of experience and success in many areas.
“There’s a lot of bad blood between PCTs and GPs, for historical reasons, a lot of tension and friction over the years, and some GPs will tell you ‘oh, we don’t want anything to do with PCTs ever again” - General Practitioner
“Lots of relationships that are built up are disrupted, now sometimes that’s an opening for new relationships and people that haven’t had a seat at the table, but often you can throw the baby out with the bathwater, and I’m a bit concerned about that” - Third sector manager
Some respondents in PCTs expressed a more general hostility to the notion of GPs taking over commissioning. “GPs have to be paid to do anything!” was an extremely common refrain from respondents who saw themselves as champions for inequalities issues, suggesting that they did not view GPs as obvious allies and that GPs had considerable work to do to establish a positive image in the eyes of these actors.
Several respondents expressed concerns that CCGs would have to start a lot of community engagement work from scratch, and develop meaningful relationships with key communities. Engagement was seen by many participants to be important not just for understanding population needs, but also in commissioning services that effectively meet those needs.
”Good commissioners get out there and talk to parents, carers, families; they have many mechanisms to understand how it feels to be receiving services” - PCT healthcare commissioner
Other respondents expressed doubts as to whether GP commissioners would even recognise the importance of finding ways to engage with the wider population, again underscoring the need for CCGs to develop partnership approaches with Local Authorities, who often had greater strengths in this area.