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Never Again?: The story of the Health and Social Care Act 2012

‘Never Again?’ tells the story of how and why the Health and Social Care Act 2012 – by far the most controversial piece of NHS legislation in more tha

‘Never Again?’ tells the story of how and why the Health and Social Care Act 2012 – by far the most controversial piece of NHS legislation in more than two decades – became law.

It relates the story of a political thriller – from the legislation’s origins 20 years ago, through the development of the 2010 white paper “Liberating the NHS” and the resultant bill; a bill so controversial that it appeared at times as though the Government might lose it.

It does so from the view point of opponents and critics, but also from the point of view of the man with whom this legislation is uniquely identified – the current health secretary.

On the way, it explains just what it was that Andrew Lansley was trying to do and why the bill was so vast and controversial.

It details the events that shaped it – most notably the Coalition’s now partly forgotten “programme for government”. That document – cooked up purely by the politicians in Downing Street over 12 days immediately after the election in May 2010 – radically reshaped the health secretary’s plans.

Sorting out the “disaster” in the “programme for government” turned what would have been merely a large shift of power and accountability within the NHS into a huge structural upheaval: one that allowed the reforms to be written up as the biggest reorganisation in the 63-year history of the NHS; and one that could become this Government’s “poll tax”.

‘Never Again?’, in particular, is a story of coalition government and coalition policy making. The act is uniquely identified with Andrew Lansley, but without the Liberal Democrats it would have been a very different bill. At the same time, without the Liberal Democrats, there would have been much less fertile ground within government for opponents to sow the seeds of their dissent. Without them, it would have undergone fewer amendments. And yet, in another twist to the coalition tale, without Liberal Democrat votes the legislation would not have passed.

‘Never Again?’ recounts:

• how Andrew Lansley was banned from talking about the detail of his plans ahead of the election
• what happened at the meeting that called “the pause” on the legislation
• how Sir David Nicholson came to be appointed chief executive designate of the NHS Commissioning Board
• how Andy Burnham revived the opposition to the bill
• and how the Coalition finessed its legislation through the House of Lords.

‘Never Again?’ also seeks to draw some early lessons from what is widely regarded as a “car crash” of both politics and policy making. But at the same time it explains why the health secretary believes that never again – or at least for the foreseeable future – will the NHS need to undergo another big structural change and raises the possibility that Andrew Lansley could yet emerge as something of a hero of public sector reform.

Lessons learned

Nicholas Timmins’ case study draws out 10 specific lessons from the story of the Health and Social Care Act. In a separate commentary, Learning the lessons from 'Never Again?' , we link those lessons to earlier work that the Institute for Government has done on:

1. policy making in opposition 2. making coalition government work 3. transitions to government 4. the role of the centre of government 5. being an effective minister 6. better policy making.

This timeline is published alongside Never Again? The story of the Health and Social Care Act 2012 by Nicholas Timmins for the Institute for Government and The King’s Fund.  It is a visual guide through the events that led to the act reaching the statute book. It sets current NHS reforms within a  historical context - from the creation of the internal market in 1989, to the establishment of the first Foundation Trust in 2004, to the passing of the most recent controversial legislation.

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• Research article
• Open access
• Published: 17 February 2017

Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

• E. W. Gadsby 1 ,
• S. Peckham 1 ,
• A. Coleman 2 ,
• D. Bramwell 2 ,
• N. Perkins 2 &
• L. M. Jenkins 1  

BMC Public Health volume  17 , Article number:  211 ( 2017 ) Cite this article

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The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.

We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.

Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.

Conclusions

Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Peer Review reports

The UK government elected in 2010 embarked on a wide-ranging program of reforms to the health and social care systems in England. The Health and Social Care Act (2012) formed the centrepiece of the reforms, introducing extensive changes to the organisation, structure and delivery of health services. As part of these changes, key public health functions were transferred from the National Health Service (NHS) to local government councils. This transfer included specialist public health staff and the budget for commissioning a range of public health services, including sexual health services, public health nursing, drug and alcohol treatment, smoking cessation and weight management services. In addition, a national public health agency (Public Health England, PHE) was established, as the national leadership body for public health to provide national campaigns and co-ordinate health protection, and as an active partner in local initiatives where appropriate [ 1 ].

During the reforms, the government highlighted a number of issues that lay behind inadequate population health outcomes. It felt the system was fragmented, lacked integration and synergies across services and had overlapping responsibilities [ 2 , 3 ]. It also felt the system disempowered public health professionals, insufficiently valuing their skills [ 3 ]. Crucially, the government argued that there was an insufficient focus on the root causes of ill health, and pointed to a lack of accountability with regards to outcomes. Issues faced in England chimed with cross-cutting themes that emerged from a review of public health in Europe, notably: the importance of inter-sectoral working, the existence of wide inequalities between and within countries in Europe, and the knowledge gaps around what public health policies and interventions are being implemented where, and which are most effective [ 4 ].

In 2012, a new European health policy framework was developed, to support action across government and society to improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems [ 5 ]. It was in this context that the UK government set out, in the English reforms, to clarify responsibilities and accountabilities, empower people and communities, and focus on the evidence of what works. They wanted a greater emphasis, at all levels, on disease prevention, and a more joined up approach, with clearer leadership. In addition, the need to achieve better results with less money was an undercurrent to the entire health and social care reforms, driven by the government’s aim to reduce their budget deficit.

Prior to the reforms in England, Primary Care Trusts (PCTs) were the NHS bodies responsible for commissioning – strategic planning and purchasing - most health services, including for public health [ 6 ]. Until 2011, PCTs also directly managed the vast majority of NHS community health services, such as district nursing, health visiting and children’s services. In 2013, PCTs were abolished and replaced by a new NHS commissioning architecture, locally led by Clinical Commissioning Groups (CCGs), and nationally led by a new independent NHS commissioning board (NHS England) [ 7 ].

Within PCTs, public health specialists tended to provide a lead role in developing strategies for meeting local health needs, and specialist clinical and public health advice to inform PCT commissioning. Whilst public health was (and remains) an inter-organisational function, with much close working between PCTs and local councils, funding remained predominantly from NHS sources, with most decisions about services and expenditure taken within an executive decision-making framework by Directors of Public Health supported by PCT Boards [ 6 , 8 ].

Public health services are now funded by a public health budget, separate from the budget managed through NHS England for healthcare. This budget is decided by the Department of Health (DoH), and managed by PHE. PHE funds public health activity either through allocations to upper-tier and unitary councils, by commissioning services via NHS England, or by commissioning or providing services itself. Most locally delivered public health activities are now commissioned or provided by local councils. The structure of local government in England is complex: there are 27 areas where services are split between upper-tier county councils (taking responsibility for social care, education, transportation and strategic planning), and smaller district councils (covering e.g. housing, leisure, environmental health and planning), and there are 125 unitary councils that provide the full range of services. All of these councils are run by elected councillors, usually affiliated to a political party, who represent and engage their local population, make key decisions, contribute to policy/strategy review and development, and conduct overview and scrutiny roles. Councils have the freedom to innovate and to make changes locally, under the ‘general power of competence’, introduced by the Localism Act 2011 [ 9 ]. There are important differences, then, in the context in which local public health commissioning is now done.

The Health and Social Care Act also introduced Health and Wellbeing Boards (HWBs) as statutory sub-committees of local councils. These boards were intended to bring together the key NHS, public health and social care leaders in each local council area to work together to co-ordinate commissioning of their services. They are thus an important part of the new health commissioning landscape [ 10 ].

A House of Commons Health Committee inquiry on public health post-2013, launched October 2015, is starting to raise some important issues related to the structures, organisation, funding and delivery of public health following the reforms [ 11 ]. However, to date, little academic attention has been paid to the impact of the reforms on public health commissioning in England. This article examines key changes to the public health system following the reforms, and explores the broad function of commissioning for health improvement within the new system. It highlights some important changes in the way public health commissioning is now undertaken, in who is doing it, and in what is commissioned. It draws on findings from a 3-year research study funded by the DoH, which examined the impact of structural changes on the functioning of the public health system, and on the approaches taken to improving the public’s health. The article critically examines these findings in the context of the intentions of the reforms to create a more joined-up system with clearer leadership and greater opportunities to improve population health.

The PHOENIX study was a 3-year research project to examine the impact of structural reforms on the functioning of the public health system in England. It was an exploratory study that took place from the time of transition (April 2013), and so could explore the ways in which the planning, organisation, commissioning and delivery of health improvement services were changing over time as the new structures bedded in. One of its objectives was to examine approaches taken to commissioning within the new system, using obesity as a focal topic.

The study incorporated multiple methods. In a scoping review [ 12 ], we analysed policy documents and responses to the reforms from key stakeholders [ 13 ], developed a picture of how the new structures were developing, and collated demographic and other data on all 152 upper-tier and unitary local councils in England. This review identified the key themes to follow up on in the next phase of the research. It also enabled the purposive selection of local councils for later case study research, conducted from March 2014 to September 2015, in five areas. The areas were purposively selected for maximum variation across a a range of characteristics related to the councils and the populations they serve (including council type, size, urban or rural location, varied socio-demographic and economic circumstances, obesity prevalence and different political control) in order to provide a diverse range of cases. The five areas (described in Table  1 ) encompassed 13 different councils, including unitary, upper-tier and a sample of lower-tier (district) councils, some of which had a variety of different sharing arrangements. This enabled an examination of multiple perspectives and inter- and intra-organisational relationships.

Within the case study areas, 103 semi-structured interviews were conducted (see Table  1 ) with 36 council public health staff; 18 elected members; 25 council non-public health staff; 13 provider organisation staff; six CCG staff and three other staff at regional levels. Three members of the research team were allocated across the case study sites to enable each researcher to develop a deep understanding of and good relationships within each area. Fifteen meetings were observed and documentary evidence was collated to enrich our understanding of the case study areas. A further five interviews were conducted with key informants outside of the case study areas, particularly to explore national and regional level issues and relationships with/within PHE.

In the autumn of 2015, a web-based questionnaire was sent to all Directors of Public Health (DsPH), and to councillors in all 152 upper-tier and unitary councils who had a public health brief. Usable responses were received from 49% of DsPH and 32% of elected members. The questionnaire was broadly a repeat of a survey conducted the previous year (not reported in this paper). The distribution of responses from local councils was highly representative overall. Data was analysed using SPSS.

Qualitative data was analysed on a case and theme-based approach, using NVIVO 10. Multi-investigator, multi-site and multi-method triangulation was used in an ongoing and iterative process of bringing together and interrogating the data. Reflexive, narrative accounts of each case study area were shared with the research team, which was made up of experts in public health, local government, ethnography, and public policy. Rich interpretations of emergent themes across the cases were developed collaboratively, paying particular attention to roles and relationships, power/autonomy, and decision-making processes. Analysis drew on a number of integrative theoretical frameworks, employing concepts and ideas drawn from a number of different paradigms [ 14 , 15 ]. Ongoing analysis of the data allowed shifts in focus according to the interplay between theory, concepts and data, enabling sensitivity to the constantly changing field of study.

Ethical approval was granted by the university research ethics committee, and research governance approvals were obtained for each case study site.

Throughout analysis, commissioning was considered as one of the broad aspects of public health activity. As a theme, it included identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance. Our research set out to examine the context for commissioning, the people/organisations involved in commissioning activities, the processes involved, and any evidence of things changing.

The context for commissioning

The transfer of public health staff and resources into local councils from PCTs was far from straightforward, and often accompanied other system reorganisations. For instance, in one of our case study areas, staff in a PCT were separated into a council public health team, one of three CCGs, or into a provider trust. One children’s public health commissioner who was formerly in the children’s joint commissioning team in the PCT with commissioning responsibilities for the whole of the 0–19 pathway, was transferred to a council team. Her former commissioning responsibilities were split amongst different organisations, and she was now responsible only for certain elements of the healthy child programme. She explained the resulting confusion:

“… It has caused fragmentation of the system and certainly for the 0–19 pathway or services for children, you know, the health services for children. It has meant that different parts of the system are now responsible for commissioning different elements of it …, which is challenging” (senior public health commissioner, council, site B).

This also had implications for the sharing of information between health and council commissioners, which this officer described as being “much more difficult for us now”.

Some public health staff chose to join PHE or NHS England, and some became part of new commissioning support organisations. There was much confusion over where staff should be transferred to (sometimes depending on the proportion of their time spent on service commissioning versus service provision), and around the organisation of budgets. There were instances where this tested relationships between councils and CCGs.

Local councils received their public health staff, resources and duties at a time of unprecedented cuts to their budgets [ 16 ]. These cuts precipitated ongoing restructures within councils which sought to streamline their organisations and reduce staffing costs. The positioning of public health teams within councils varied. Our survey found that 26% ( N  = 73) of the public health teams were distinct public health directorates; 52% were sections of another directorate; and 22% had other arrangements, including merged, distributed and mixed models. DsPH also had different levels of access to key council decision-making bodies (53% of DsPH respondents were members of the council’s most senior corporate management team), and different line-management structures (47% said that they were managerially responsible to the council’s chief executive; 53% were managed by a range of other directorate heads). Consequently, DsPH were not always in the best place for strategic influence in the council.

Commissioning processes and people involved

Decision-making within councils was found to be very different to that within PCTs. Decisions about how to spend money were subject to a greater range of decision makers and wider consultation, both across the council and amongst the public, than before. Elected members are the key decision makers within councils; the role of officers, including those in public health, is to support them. Elected members, therefore, were influencing the priorities and actions of the public health team, sometimes overtly and sometimes more subtly. 92% of elected members responding to our survey ( N  = 38) said they felt always able (45%) or quite often able (47%) to influence the priorities of the public health team. In our case studies, we saw how this influence might operate more subtly, perhaps according to the ideologies and interests of the elected member, or the politics of the council. For instance, in one Conservative-led council, the elected member explained that he would have a very difficult job persuading his cabinet to significantly increase spending on smoking cessation: “They’re not particularly interested in it, they think … ‘oh well if people smoke themselves silly, let them smoke themselves silly’” (elected member, council, site A).

Compared with the NHS, local councils take different approaches to prioritisation and commissioning, influenced in part by over 15 years of implementing ‘Best Value’ Footnote 1 . The processes of commissioning (and new procurement laws) within a council have had to be learned by incoming public health staff. At the same time, public health staff have tried to educate councillors in public health commissioning.

Several commissioning officers who had worked within councils prior to the reforms (e.g. in adult or children’s social care directorates) and who moved, following the reforms, into the public health teams, talked about differences they observed in how commissioning was done. One, referring to her incoming public health colleagues, explained:

“We were faced with a lot of ignorance about commissioning - local authority style commissioning and business processes - amongst our colleagues… I was shocked actually by the lack of understanding of what we had been doing or what we did [as local authority commissioners]” (commissioner, council, site B) .

Another talked about the differences between commissioning in PCTs and commissioning in the councils. She explained that “public health has commissioning responsibilities now in a way that they didn’t in the old PCT”. She described commissioning in the former PCTs as comparatively less ‘robust’, with less accountability, and less scrutiny of performance and outcomes data:

“ there’s much stronger scrutiny in local government and that’s all areas of business and it’s something that we’ve had to really work with our providers in NHS specifically around understanding” (commissioner, council, site A) .

From the point of view of providers, however, the sometimes rather narrow outcomes-based scrutiny that services were now subjected to was not always appropriate for complex public health interventions. For instance, the provider of a range of obesity prevention services in one of our case study areas complained that the focus on outcomes in terms of body mass index reductions belied the fact that most of their time and resources were spent on engaging communities and developing relationships with schools and others. The outcomes of this type of activity, however, are impossible to measure.

Having a distinct public health grant for the first time enabled DsPH to take a different approach – a more strategic approach - to the allocation of the public health budget. A public health officer in one of our sites described how, in the PCT, they were sometimes left ‘scrabbling’ around for funds, when public health priorities and PCT priorities were not always well matched. However, with a ring-fenced budget, they were able to plan how best to match spending against their local priorities. The leader of a council in site A explained how they were prepared to completely shake up the way in which the public health grant was spent: “ We’ve got to start at reviewing; is that delivering to the right priorities or not? Is it value for money or not? And what should we stop doing and what should we start doing? ” Indeed, this process of whole-scale service reviews for specific areas (such as obesity) was demanded by councillors in all of our case study areas. For public health officers, this sometimes gave them the freedom to pursue quite different approaches.

Decision-making across the local system following the reforms was intended to be more co-ordinated. However, with commissioning responsibilities now fragmented between NHS England, PHE, local councils and CCGs, our research found that co-ordination was proving to be difficult. Moreover, the lack of clarity about responsibilities sometimes led to delays in the commissioning of services, and/or tensions in the relationships between organisations. Commissioning across an obesity pathway, for instance, involves councils (for broad obesity prevention and non-intensive weight management services), CCGs (for specialist obesity services) and NHS England (bariatric services) [ 17 , 18 ]. Across England, we know that there are significant gaps in this pathway, with a particular lack of specialist obesity services [ 19 , 20 ]. Following the reforms, there was a great deal of confusion about whose responsibility it was to commission these services.

It is clear that, as with many public health interventions, if weight management and obesity prevention services are to achieve their objectives, primary and community care providers play a vital role. The presence, absence, type and success of health improvement services commissioned by councils have important implications for NHS work. However, there is now a greater disconnect between public health officers and NHS commissioners. In response to our survey, 48% of DsPH ( N  = 69) said they felt ‘less able’ to influence local CCGs than before the reforms. In our case study sites, we found that evidence of meaningful engagement between public health teams and CCGs was limited. This HWB chair felt that CCGs had become disengaged from public health:

“ I think we’ve got to persuade the CCG that, in particular, public health is everybody’s business, it’s not just the local authority’s business. … they see public health as a separate entity at the moment, and not part of an integrated health economy” (Chair HWB, council, site C) .

HWBs were meant to be the mechanism for co-ordinating commissioning across NHS, social care and public health at the strategic level. Our survey found that amongst DsPH ( N  = 65), 48% felt the HWB was ‘definitely’ instrumental in identifying the main health and wellbeing priorities, and 45% felt it had ‘definitely’ strengthened relationships between commissioning organisations. However, less than 5% felt that the HWB was ‘definitely’ making difficult decisions, and only 28% felt that it had ‘definitely’ begun to address the wider determinants of health. A further complication with co-ordinating across the system and addressing wider determinants is that in two-tier councils, many of the functions that public health are expected to work across are based in multiple lower-tier district councils. Public health officers must therefore build relationships with a greater number of different organisations, all with their own priorities and ideas. In addition, these district councils often have a limited voice on HWBs. It is perhaps partly for this reason that some HWBs were not seen to be significantly engaging with the public health agenda. As this HWB chair explained:

“We have a very strong focus on integration, Better Care Fund – all that side of things. I’m conscious sometimes of an element of criticism … there’s always a challenge to say, ‘Are you actually thinking enough about long term determinants and all the sort of public health agenda’ …” (Chair HWB, council, site A).

What has changed?

Our research suggested that, as a result of the reforms, public health commissioning was changing on a number of levels. Firstly, money was being used in different ways. One indication of this was the way in which the ring-fenced public health budget was being used to invest in other departments in the majority of councils (see Fig.  1 ). Given the huge cuts councils were having to make, most DsPH felt that, now the public health budget was contained within the council, it was expected to contribute to the overall savings they needed to make. Many seemed reconciled that the budget would now be used to fund other services – in many cases, services that would have been cut (e.g. children’s centres) had public health funding not been available. And in our case studies, public health officers talked about the opportunities this sometimes presented, in terms of embedding public health activities and objectives within other council services and providing more joined-up ways of thinking and working.

Use of public health budget to invest in other council departments in previous 12 months

Secondly, there were many changes being made to the commissioning of health improvement services (see Fig.  2 ). The move to local government prompted public health commissioners to look at services and contracts anew. In addition, councils tended towards shorter contracts and more frequent retendering of services than the NHS. All our respondents had started the process of retendering within 2 years. But we also saw the majority of responding authorities ( N  = 64–67) having set up new services (73%), changed provider of existing services (90%), re-designed existing services (94%) and de-commissioned services (69%). In our case study areas we saw that extensive commissioning changes were sometimes occurring as a result of changes in local area arrangements, for instance, where several areas (former PCTs) were brought together into one (council). Other commissioning changes, however, were as a result of service reviews that were very critical of service outcomes.

Changes made by councils to services commissioned under public health budget in last 12 months

Our surveys asked for more information about changes that were being made to obesity commissioning. DsPH commented that they were wanting to move away from ineffective schemes, increase their focus on children, use new providers and create a more integrated pathway. All these changes were resulting in insecurity in the provider landscape.

Finally, there were changes to the size and profile of the public health teams responsible for commissioning health improvement services. DsPH were asked whether there had been changes in the last 12 months to the size and composition of their public health team. 28% ( N  = 72) reported that they had fewer public health specialists. 15% reported they had more business managers/commissioning support staff, and 22% ( N  = 54) said they had more ‘other’ staff (not falling into the DPH, specialist, analyst or commissioning support categories). In our case study sites, public health officers talked of the need to address skill gaps within their team in response to working in the new environment. In one of our sites, for instance, the public health commissioning team (made up of non-public health specialists) had been significantly bolstered. The team of public health specialists had been correspondingly reduced.

It was not easy to tell, at this juncture, whether these observed changes in commissioning had resulted in a significantly different set of activities being commissioned. However, there were early signs of some general shifts occurring. In three of our case study areas, we observed a shift towards the commissioning of more holistic ‘healthy lifestyle’ services, bringing together weight management, smoking cessation, alcohol reduction, sexual health services, and so on. In two of our councils, we saw a shift (at least in rhetoric) towards ‘whole council’ approaches, for instance, where they were seeking to address a broader range of factors influencing obesity, particularly by working across council departments. We witnessed a greater recognition of public health objectives and expected outcomes in a wider range of council services as a result of public health investment. And we saw public health staff working hard to influence the wider workforce. Particularly during the transition phase, as public health were settling into their new homes, a number of programmes including learning events, information sharing, and engagement events were targeted at elected members and non-public health officers across the council.

The reforms expressed a clear intention to simplify and streamline a previously complex, fragmented system. The transfer of public health responsibilities into local councils was to ensure that public health outcomes were embedded across a council’s functions. The creation of HWBs was to ensure strategic direction across organisations.

The functions of the now extinct PCTs were spread across CCGs, councils and provider organisations, creating a more complex organisational picture than before the reforms, with more complex accountability and governance structures. Moreover, there was continued upheaval in the system, with elements such as CCGs and public health teams merging, the PHE regional tier ‘downsizing’, and local councils constantly restructuring as they tried to cope with substantial budget cuts. Fragmentation is a problem common to many health systems, and is a condition related to the tendency within health care planning to focus and act on the parts without adequately appreciating their relation to the evolving whole [ 21 ]. There is a constant challenge to create a system focused on relationships across the whole – whole people, whole systems, whole communities. It is often these relationships across the whole that suffer in the context of financial restraint and continual change [ 22 ].

The move of public health into local councils in England created a new working environment for commissioners, public health practitioners and providers. Our findings have demonstrated how, in this new environment, existing public health capacity has been both freed and stifled. Public health professionals have the opportunity to take on a more significant role in shaping local places, but will need to find a balance between ‘service’ public health and academic ‘social medicine’ [ 23 ].

The considerable literature on decentralisation suggests that the transfer of authority and resources to local government might offer significant opportunities to improve access to health and other care services, to provide services that are better aligned to needs and local preferences, and to allow for increased flexibility and transparency [ 24 – 26 ]. However, the reforms in England simply moved public health responsibilities at the local level from executive decision-making bodies (PCTs) to democratically governed councils. Whilst PCTs had the same ‘local’ focus as councils, they were historically more directly accountable to central government, and, with a few exceptions, were poor at developing local ‘bottom-up’ methods for making NHS services more user-responsive [ 27 ]. Councils, on the other hand, have been subject to a longer experience of competitive tendering and service commissioning than the NHS [ 28 ], and tend to have a more structured approach for community engagement and user-involvement embedded in their organisational culture [ 29 ]. As a result, there appears to have been a shift in how public health commissioning is performed, from a more specialist-led investment approach to a more ‘business’-orientated approach adopted by many local councils, using best value frameworks.

In the new environment, there seems to be more opportunity for variation across the country in what activity is commissioned, and in who provides it (as well as how, where and to whom). The Localism Agenda [ 9 ] gives councils more freedom to innovate, to both drive down costs and meet local needs [ 30 ]. Considerable discretion was afforded to individual councils to interpret the full and detailed scope of their new functions and services [ 31 ]. This was important, given the independence of councils as democratic organisations, but it means that public health decision-making is now less amenable to central government control.

In the absence of strong central control, it is important to question the extent to which local problems can be solved locally without risking geographical inequity of services which underpin basic human rights [ 32 , 33 ]. For the next couple of years, the annual public health budget devolved to local government in England will be around £3.3 billion (reducing by an average of 3.9% every year in real terms until 2020) [ 34 ]. Prior to the reforms, this budget would have been spent by PCTs, who were accountable for that spend to the DoH, via regional NHS authorities (now abolished) who were mainly concerned with overall NHS expenditure and financial sustainability of NHS healthcare services. Following the reforms, whilst the public health outcomes framework gives a clear sense of outcomes the DoH expects to see, the accountability for spending money is much weaker. Beyond a basic report to the Department on how the budget has been spent, there is very little role for formal state-driven accountability. In a way most uncharacteristic of the NHS, PHE has emphasised that it is there to support local councils, not performance manage them. Instead, there is a reliance on sector-led improvement, whereby councils review and support each other’s performance [ 35 ]. In addition, public health commissioning is coming under much closer scrutiny from elected members within the local council. Our research supported the idea that we can expect to see increasing variation in services, but it is far from clear what impact this will have on variations in outcomes.

Public health officers moving from the NHS to local councils have sometimes struggled to adjust to this different relationship with central government. From the point of view of commissioners, the lack of guidance and clarity from Government was often found to be unhelpful. In particular, public health officers expressed the need for more timely information, for instance, regarding responsibilities for commissioning across the fragmented system, or how the in-year budget cuts would be implemented [ 36 ]. In the absence of detailed information, public health teams were sometimes forced to make commissioning decisions based more on expediency than on need. In the new system, the DoH is defined as the ‘system leader’, improving people’s health and wellbeing through its stewardship of the public health system [ 37 ]. The concept of health stewardship implies a broad over-arching responsibility over the functioning of the system as a whole and, ultimately, over the health of the population [ 38 ]. However, we suggest that central government in England has yet to resolve some important stewardship issues, particularly around its role in securing resources, balancing competing interests and demands, and assuring delivery in the context of localism and the move of public health into local government. Moreover, there was little in our research to suggest that PHE have sufficient capacity, or have yet developed the strong relationships required, to provide meaningful support to local partners in the delivery of their vision.

Public health officers have also had to adjust to different roles and relationships relative to other actors at local level. Directors of public health were previously key decision makers on the executive boards of PCTs. Whilst they were often the first to be pushed back if cuts were required or budgets exceeded, DsPH had clear authority with regards to public health prioritisation. Following the reforms, they are expert advisers to elected members. Leadership for public health is more dispersed; decision-making is now more complex, and arguably subject to greater political ideology and personal interest. There may also be unforeseen consequences arising from the outcomes-based scrutiny of complex public health interventions, and from increased insecurity within the provider landscape. Many public health interventions require a long time-frame in which to bring about significant population health improvements. This doesn’t sit well with the short-termism of contemporary politics. As local councils struggle to cope with tighter budgets, public health officers may find it harder to convince their elected members of the added value of some of the public health services they commission.

Our research has highlighted the huge amount of change occurring in the commissioning (and decommissioning) of health improvement services in England. Whilst it will be important for the wider health system that key public health services are protected and improved (for instance, in smoking cessation, weight management and sexual health services), the public health specialists will need to capitalise on bringing about positive change through closer integration with the strategy and activity of the council. Commissioning for health improvement requires commissioners to focus on the modifiable determinants of health, taking a pro-active approach to improving individuals’ life chances and reducing social inequalities, rather than waiting until people are already ill and commissioning reactively. Local councils, due to their wider scope and responsibilities, are better placed than the NHS with its largely clinical orientation, to address a broad range of determinants, such as lifestyles, community, local economy and activities [ 30 ]. Our research, like the many case studies highlighted in a range of Local Government Association reports [ 39 – 42 ] has identified a range of positive examples where stronger and more direct public health involvement and influence across councils has brought about new opportunities. In their new ‘home’, and with the right support from their council, public health officers can be afforded the freedom to approach public health challenges in new ways. Local councils are also more adept than NHS organisations at broader level consultation and community engagement, which might afford new opportunities in line with the Ottawa Charter recommendations for public participation and empowerment [ 43 ].

The NHS continues to have a vital part to play in population health improvement, and the reforms hoped to bring about improved synergies between public health, NHS and social care. However, with public health moving ‘arms-length’ to the NHS, both health services commissioners and providers are becoming more remote to the local public health systems. Moreover, the vital co-ordination role of HWBs is not always working well locally [ 10 ]. Some health improvement services could, as a result, end up being disconnected from each other and from wider support. Similarly, services that are crucial to the achievement of health service objectives (such as reducing premature mortality from the major causes of death), but which are commissioned or provided by the council (e.g. weight management, smoking cessation and alcohol services), are at risk of being cut or changed. Our research has highlighted that there is much change in the way public health commissioning is done, who is doing it, and what is commissioned. Time (and further research) will tell if these changes are to result in improved outcomes and reduced inequalities. However, until there is a strong sense of shared ownership across local systems, and ‘whole system’ commissioning at local level, any opportunities afforded by the reforms to the public health system might be outweighed by the challenges of fragmentation and budget cuts.

We found that the system created by the reforms was confused, continually changing, and - from the point of view of commissioning - more fragmented than before. In some ways, the move of public health into councils has brought about some of the opportunities associated with decentralisation – in particular, allowing for increased flexibility. However, most public health commissioners were essentially moved from one local organisation (NHS), to another (council), so the comparisons with decentralisation are limited. In this new local environment, former public health capacity has been at the same time freed and stifled. Public health commissioning is being more strongly influenced by a new set of decision-makers in the form of democratically elected councillors, with their own local knowledge, ideologies, and experiences. Meanwhile, many councils are bringing a more business-oriented approach to bear on public health commissioning, with greater scrutiny of outcomes in relation to spend. This is challenging the public health specialists and provider organisations, and changing the shape of health improvement services. Whilst we can expect to see increasing change and variation in services across England, it is far from clear what impact this will have on outcomes and on variations in outcomes.

The Duty of Best Value makes clear that councils should consider overall value – including social value – when considering service provision. Under the general Duty of Best Value, local authorities should “make arrangements to secure continuous improvement in the way in which its functions are exercised, having regard to a combination of economy, efficiency and effectiveness” https://www.gov.uk/government/publications/best-value-statutory-guidance--4.

Abbreviations

Clinical Commissioning Group

Department of Health

Directors of Public Health

Health and Wellbeing Board

National Health Service

Primary care trust

Public Health England

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Acknowledgements

We are grateful to our case study sites for allowing us to spend so much time with them and for being so open in discussing their work. We are also grateful to the survey and interview respondents for giving up their valuable time to respond to our questions. The project’s stakeholder group have provided valuable guidance and support throughout the research.

This research on which this article is based was funded by the UK Department of Health. The views expressed are those of the researchers and not necessarily those of the Department of Health.

Availability of data and materials

Data will not be shared due to the difficulties of ensuring anonymity of sites and individuals.

Authors’ contributions

SP managed the research on which this article is based. EG, AC, DB, NP and LJ carried out the research. LJ conducted the analysis of the surveys. EG, AC, DB, NP and SP were involved in analysing the case study data. EG drafted the manuscript. EG, SP, AC, DB, NP and LJ helped to interpret the data and edit the manuscripts. EG, SP, AC, DB, NP and LJ approved the final version of the manuscript.

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The authors declare that they have no competing interests.

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Not applicable.

Ethics approval and consent to participate

Approval was sought and granted from the University of Kent’s School of Social Policy, Sociology and Social Research Ethics Board (SRCEA No. 112), and research governance approval was obtained for each case study site in respect of NHS interviewees from the Health Research Authority (15 July 2015/182754). Written, signed consent was obtained from the heads (leaders and/or chief executives) of all local councils within the case study areas and every individual interviewed within the study.

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Gadsby, E.W., Peckham, S., Coleman, A. et al. Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?. BMC Public Health 17 , 211 (2017). https://doi.org/10.1186/s12889-017-4122-1

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Health and Social Care Act 2012: fact sheets

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Peer-reviewed

Research Article

Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America

Roles Investigation, Methodology, Writing – review & editing

Affiliation Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America

Roles Conceptualization, Investigation, Methodology, Supervision, Writing – review & editing

Affiliation Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom

Roles Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – review & editing

• James A. Lopez Bernal, 
• Christine Y. Lu, 
• Antonio Gasparrini, 
• Steven Cummins, 
• J. Frank Wharham, 
• Steven B. Soumerai

• Published: November 14, 2017
• https://doi.org/10.1371/journal.pmed.1002427
• Reader Comments

26 Feb 2018: The PLOS Medicine Staff (2018) Correction: Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis. PLOS Medicine 15(2): e1002527. https://doi.org/10.1371/journal.pmed.1002527 View correction

The 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits.

Methods and findings

We conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%–1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%–2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were −0.2% (95% CI −0.6%–0.2%; p = 0.257), −0.2% (95% CI −0.6%–0.1%; p = 0.235), and 0.0% (95% CI −0.5%–0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen.

Conclusions

Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.

Author summary

Why was this study done.

• In 2012, the government introduced major reforms to the National Health Service (NHS) in England, which handed budgets for specialist care to GP-led organisations known as Clinical Commissioning Groups.
• This gave GPs a major new role in purchasing hospital-based specialist medical care for patients, in addition to their existing role as “gatekeepers” to specialist care.
• An expected effect of this policy was that there would be a shift in care away from expensive hospital-based care and towards the community.
• Our study aimed to evaluate the potential impact of these reforms on levels of hospital activity including outpatient visits to specialists and inpatient admissions.

What did the researchers do and find?

• We examined trends in all NHS specialist visits and hospital admissions between 2007 and 2015 in order to examine changes in trends following the reforms.
• We included equivalent trends in Scotland, where the reforms did not occur, as a control series.
• We found no change in hospital admissions in either country.
• However, in England we found an increase in the trend of outpatient specialist visits following the reforms, equivalent to approximately 3.7 million additional specialist visits between the time the policy was implemented and the end of the study period (compared to expected).

What do these findings mean?

• Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not linked to a decrease in hospital admissions and was associated with an increase in outpatient specialist visits.
• Further research is needed to establish the appropriateness of these visits and the reasons for the increase.
• However, these findings suggest that other interventions may be needed in order to shift more patient care into the community.

Citation: Lopez Bernal JA, Lu CY, Gasparrini A, Cummins S, Wharham JF, Soumerai SB (2017) Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis. PLoS Med 14(11): e1002427. https://doi.org/10.1371/journal.pmed.1002427

Academic Editor: Aziz Sheikh, Edinburgh University, UNITED KINGDOM

Received: April 26, 2017; Accepted: October 5, 2017; Published: November 14, 2017

Copyright: © 2017 Lopez Bernal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was funded by a UK Medical Research Council Population Health Scientist Fellowship awarded to JLB – Grant Ref: MR/L011891/1, https://www.mrc.ac.uk/ . No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: CCG, Clinical Commissioning Group; CITS, controlled interrupted time series; DH, Department of Health; GP, general practitioner; HES, Hospital Episode Statistics; HSCA, Health and Social Care Act; NHS, National Health Service; PCT, primary care trust; RECORD, REporting of studies Conducted using Observational Routinely-collected health Data; SHA, Strategic Health Authority; SMR, Scottish Medical Records

Introduction

The 2012 Health and Social Care Act (HSCA) in England has been described as “the biggest and most far reaching [reorganisation] in the history of the NHS” [ 1 , 2 ]. The reforms centred around the introduction of general practitioner (GP) led Clinical Commissioning Groups (CCGs), which received about two-thirds of the National Health Service (NHS) budget (£66.8 billion in 2015–2016) to commission (plan and contract) secondary care, including hospital and specialist services [ 1 ]. CCGs represent all GP practices in their local area, and the key difference from the previous commissioning structures was purported to be a major new role for GPs as key decision makers in the commissioning process [ 1 , 3 , 4 ].

Health policy experts and parliamentary and professional bodies have hypothesised that GP-led commissioning could potentially lead to reductions in referrals to specialist care, as either an intended or unintended consequence of the Act [ 5 – 10 ]. They theorise that by giving the gatekeepers, who control access to specialist care, a greater role in budget holding and the purchasing of specialist care, they may be incentivised to reduce referrals [ 5 , 6 ]. Indeed, Smith and Mays suggest that the primary rationale for GP-led commissioning is to encourage a shift away from expensive secondary care towards more community-based care [ 6 ]. Furthermore, 2 out of the 3 main reasons cited by the government for introducing the reforms centred around a need to control costs, although the mechanisms by which GP-led CCGs would achieve cost savings were not made explicit [ 4 ]. While the potential for much-needed cost savings in the NHS as a result of reduced secondary care activity has been viewed positively, some—including the National Audit Office and the Royal College of Surgeons—have raised concerns that a reduction in referrals as a consequence of the HSCA and policies introduced by CCGs could result in inequitable rationing of care and missed diagnoses and that their role in commissioning presents GPs with a conflict of interest [ 7 – 10 ].

CCGs and GPs could reduce secondary care activity through various means, including restricting referral criteria, developing community-based care models, investing in preventative healthcare, or promoting services to prevent readmissions [ 6 , 9 , 10 ]. There also exist potential incentives for them to do so: reducing expensive care would allow CCGs to invest savings in other services. Furthermore CCGs are required to maintain a surplus; otherwise, they cannot access additional funding in the form of a “Quality Premium” of up to £5 per person within the population covered by the CCG person [ 11 ]. In addition, there are incentives to individual GPs: savings from reduced specialist visits and hospitalisations could allow investment in community-based services provided by GP practices themselves; also, some CCGs have introduced direct payments of £6,000–£11,000 to GP practices for reducing referral rates [ 7 , 8 ]. Nevertheless, whether these provide a real incentive in practice depends on how engaged GPs feel with the new commissioning organisations, how much responsibility they feel for their budgets, and how much influence they have on the commissioning process. Previous policies that have begun with an intention to place GPs at the centre of commissioning have ultimately resulted in the formation of bureaucratic bodies that have become detached from local practitioners [ 6 ]. Furthermore, given existing evidence that increasing GP workload may increase referral rates, it is possible that the increased administrative burden associated with their new commissioning role could instead result in an increase in referrals [ 12 , 13 ].

We use a controlled interrupted time series (CITS) design to compare changes in the trends of specialist referrals and hospital admissions in England before and after the HSCA with those in Scotland, where the reforms did not occur. We hypothesise that the 2012 HSCA was associated with a reduction in specialist visits and hospitalisations.

Ethical approval was obtained from the London School of Hygiene and Tropical Medicine Observational/Interventions Research Ethics Committee (LSHTM Ethics Ref: 10505).

The intervention

The 2012 HSCA introduced broad ranging and complex reforms to the NHS and public health services in England. These have been described in more detail elsewhere [ 1 , 2 , 4 , 14 , 15 ]. The principal change was in the way secondary care services were commissioned within the NHS. Prior to 2012, regional healthcare administrative bodies known as primary care trusts (PCTs) and Strategic Health Authorities (SHAs) were responsible for all commissioning. These were abolished as part of the Act and were replaced by CCGs. CCGs are led by a governing body, which includes a representative from each member GP practice, lay members, a secondary care doctor, and a registered nurse [ 3 ]. CCGs were first introduced in shadow form (working alongside PCTs) in April 2012 following the enactment of the HSCA; they then took over full budgetary responsibility in March 2013 [ 1 ].

While a control is not required in interrupted time series studies, the primary comparison being between preintervention and postintervention trends within the study population, a control population can help to exclude additional confounding events and cointerventions. Healthcare is a largely devolved power in the United Kingdom and the HSCA only applied to England; therefore, we considered the other 3 nations of the UK (Northern Ireland, Scotland, and Wales) as potential controls. These are neighbouring countries with similar population demographics ( S1 Table ), similar health systems, and shared political structures. Data equivalent to those in England were not available from Northern Ireland; therefore, it was excluded. We chose Scotland as the control, as preintervention data were more stable than for Wales. We also include an analysis as a supplementary appendix with Wales as the control ( S2 Table , S1 and S2 Figs).

Data and study population

We obtained quarterly data on all hospital admissions and outpatient specialist visits in NHS hospitals in England between April 2007 and December 2015 from the Health and Social Care Information Centre: Hospital Episode Statistics (HES) [ 16 ]. Hospital admissions include all inpatients in NHS hospitals as well as NHS-funded inpatients in the private sector. NHS outpatient activity in England is hospital based; specialist visit data include outpatients in English NHS hospitals and NHS-funded outpatients in the private sector. Our outcomes were total hospital admissions, elective (planned) and emergency (unplanned) admissions, total first specialist visits (excluding follow-up appointments), and GP-referred first specialist visits. Equivalent data for Scotland were obtained from the NHS Scotland Information Services Division: Scottish Medical Records (SMR) [ 17 ]. We obtained demographic data for England and Scotland from the Office for National Statistics including midyear population estimates (for denominators), age and sex distribution, crude birth rate, and crude death rate [ 18 ]. The Scottish hospital admission data did not include obstetric and psychiatric hospitals and the outpatient visit data did not include visits to nurses, dentists, or other allied health professionals. We therefore excluded these categories from the English data to make the 2 datasets comparable. Data quality reports identified a coding error in the outpatient data prior to April 2010 (3 years before the introduction of the policy); we therefore excluded these data from the analysis [ 19 ]. The raw data are provided in the supplementary appendix ( S1 and S2 Data ). A complete list of the data codes and algorithms used in the data extraction is also provided in the supplementary appendix ( S3 and S4 data ).

Statistical analysis

We used a CITS design, which allowed us to control both for preintervention trends in the outcome and for potential confounding events that would have affected both the control and the study groups. Although a Poisson distribution is assumed for individual counts, we had very large numbers and the aggregate data were well approximated by a Gaussian distribution (log transformed). Therefore, we used a simple linear segmented regression model to estimate the change in trend in hospital admissions and outpatient visits following the introduction of the HSCA [ 20 ]. In order to account for the year during which CCGs were in shadow form, we allowed a one-year phase-in period by excluding the second quarter of 2012 to the first quarter of 2013 from the analysis. We modelled the association as a slope change rather than an immediate level change because choice of providers and referral patterns were likely to change gradually when existing contracts expired and new models of care developed [ 1 ]. Adjustments were made for any seasonal effect using a Fourier term [ 20 ].

We first estimated the slope changes in England and in Scotland independently. We then used an interaction model for the CITS to estimate the additional trend change in England over and above any change in Scotland, while controlling for any difference in the preintervention trends of the 2 groups ( S1 Text ). We examined the preintervention data a priori for linearity and autocorrelation at different lags using scatterplots, plots of residuals, and partial autocorrelation functions [ 20 ]. A linear trend provided a reasonable fit for all outcomes in the primary model. We included an autoregressive term at the appropriate lag to adjust for any detected autocorrelation. All analyses were conducted using Stata version 14.

The original study protocol from the ethics application is available as a supplementary appendix ( S1 Protocol ). The analysis has only differed from this protocol in that Scotland was selected as the primary control, as it had the most stable data; Wales was included as an additional control following reviewers’ recommendations. Northern Ireland was not included as equivalent data to that in England was not available. Furthermore, in this protocol, we also proposed including patient experience measures as secondary outcomes; this was ultimately not included within the current study but we plan to conduct a future study looking at the potential impact on patient experience.

This study is reported as per the REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement ( S1 Checklist ).

Population characteristics

Age and sex distributions were similar in both England and Scotland ( Table 1 and S1 Table ). Both populations were slowly aging; the proportion aged 60 or older increased from 21.6% to 23.0% in England and from 22.3% to 24.0% in Scotland. The crude birth rate was consistently about 1.8 per 1,000 higher in England than in Scotland while the crude death rate was consistently about 1.5 per 1,000 lower.

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https://doi.org/10.1371/journal.pmed.1002427.t001

Changes in outpatient specialist visits

Changes in trends of specialist visits are shown in Fig 1 and Table 2 . Absolute counts and the rate per 1,000 for each quarter are presented in Table 3 . In England, total specialist visits rose slowly by 0.5% per quarter (from 84.7 per 1,000 in quarter 2 [Q2] 2010 to 87.2 per 1,000 in Q1 2012) in the baseline. After the intervention, they rose approximately 3.6 times faster at 1.5% per quarter (from 90.0 per 1,000 in Q2 2013 to 104.6 per 1,000 in Q4 2015). This was equivalent to an increase in slope (additional quarterly increase) of 1.1% (95% CI 0.7%–1.5%), which resulted in a 12.7% higher rate of specialist visits (647,000 additional visits) by the end of the postintervention period in Q4 2015, compared to the underlying (counterfactual) trend. The slope increase was even more marked for GP-referred visits. During the preintervention period, these had a flat trend at 48.3 visits per 1,000 per quarter (trend 1.000, 95% CI 0.998–1.002). After the intervention, this trend increased by 1.6% per quarter (from 49.1 per 1,000 in Q2 2013 to 57.6 per 1,000 in Q4 2015). This was equivalent to an increase in slope of 1.6% (95% CI 1.2%–2.0%) per quarter, which resulted in a 19.1% higher than expected rate of specialist visits (507,000 additional visits) by the end of the study period. For those outcomes that showed strong evidence of a trend change (total and GP-referred specialist visits in England), we have presented observed compared to expected counts in the postintervention period in Table 4 . Total specialist visits had weak evidence of seasonal effect with peaks during Q3 (Fourier sin wave p = 0.055, cos wave p = 0.010).

Red o = England, blue x = Scotland. Lines = deseasonalized linear trend. Vertical lines delineate the intervention phase (between quarter 2 [Q2] 2012 and Q2 2013). The data underlying this figure are presented in Table 3 . GP, general practitioner.

https://doi.org/10.1371/journal.pmed.1002427.g001

https://doi.org/10.1371/journal.pmed.1002427.t002

https://doi.org/10.1371/journal.pmed.1002427.t003

https://doi.org/10.1371/journal.pmed.1002427.t004

Specialist visits in Scotland, however, showed no significant change after the policy. Total specialist visits and GP-referred specialist visits almost level at about 72 per 1,000 per quarter (preintervention trend 1.002, 95% CI 0.999–1.006; postintervention trend 1.000, 95% CI 0.996–1.003) and 47 per 1,000 per quarter (preintervention trend 1.002, 95% CI 0.998–1.005, postintervention trend 1.000, 95% CI 0.996–1.003), respectively, throughout the study period.

After controlling for trends in Scotland, the CITS analysis produced similar results. The magnitude of the change in slope in total specialist visits in England increased slightly to 1.4% (95% CI 0.6%–2.1%) per quarter (a 15.9% higher rate by the end of the study period). The change in trend in GP-referred specialist visits increased to 1.9% (95% CI 1.1%–2.7%) per quarter (a 22.5% higher rate than expected by the end of the study period).

The magnitude of the differential increase in trend in England was even greater when using Wales as a control series, although this was partly due to an independent reduction in the trend in Wales ( S2 Table and S1 Fig ).

Changes in inpatient hospitalisations

Changes in trends in hospitalisations following the HSCA are shown in Fig 2 and Table 2 . Absolute counts and the rate per 1,000 for each quarter are presented in Table 5 . In England, there were slowly increasing trends in all hospitalisations during the baseline period. Total hospitalisations increased by 0.5% per quarter (from 60.1 per 1,000 in Q2 2007 to 65.5 per 1,000 in Q1 2012), elective admissions increased by 0.6% per quarter (from 31.7 to 35.7 per 1,000), and emergency admissions increased by 0.3% per quarter (from 22.9 to 24.5 per 1,000). Total hospitalisations and emergency hospitalisations had a seasonal effect with winter peaks in Q4 (emergency hospitalisations Fourier terms: sin wave p = 0.002, cos wave p = 0.039). There were no statistically significant changes in any of these trends following the HSCA. Slope changes were −0.2% (95% CI −0.6%–0.2%), −0.2% (95% CI −0.6%–0.1%), and 0.0 (95% CI −0.5%–0.4%) per quarter for total, elective, and emergency hospitalisations, respectively.

Red o = England, blue x = Scotland. Lines = deseasonalized linear trend. Vertical lines delineate the intervention phase (between quarter 2 [Q2] 2012 and Q2 2013). The data underlying this figure are presented in Table 5 .

https://doi.org/10.1371/journal.pmed.1002427.g002

https://doi.org/10.1371/journal.pmed.1002427.t005

Trends in Scotland were flatter during the baseline. Total hospitalisations increased by 0.2% per quarter (from 54.0 to 55.9 per 1,000), elective admissions increased by 0.20% per quarter (from 29.9 to 31.1 per 1,000), and emergency admissions increased by 0.2% per quarter (from 24.1 to 24.8 per 1,000). Again, there was no evidence of any change in these trends after the HSCA: slope changes were −0.3% (95% CI −0.7%–0.2%), −0.1% (95% CI −0.7%–0.4%) and −0.5% (95% CI −1.1%–0.1%), respectively.

The results of the CITS analysis were again similar. The differential slope changes in England (that is, the additional quarterly change following the HSCA after controlling for trends in Scotland) were: 0.0% (95% CI −0.6%–0.6%) per quarter for total hospitalisations, −0.1% (95% CI −0.7%–0.5%) per quarter for elective hospitalisations, and 0.2% (95% CI −0.5%–1.0%) per quarter for emergency hospitalisations.

Results using Wales as a control instead of Scotland were similar ( S2 Table and S2 Fig ).

To our knowledge, this is the first study of the potential impact on secondary care activity of a universal, national policy that gave control of an unprecedented two-thirds of the English NHS budget to GP-led CCGs. Contrary to the underlying hypothesis, we found no evidence of a reduction in hospitalisations or specialist visits in England following the HSCA. Moreover, we found evidence of an increase over and above the underlying trend in specialist visits in England, with no comparable increase in Scotland, where this policy did not occur. This increase was equivalent to approximately 3.7 million additional specialist visits since the policy was implemented (compared to those expected), of which the majority (approximately 2.9 million) were GP referred.

We used a robust CITS design. By modelling long-term underlying trends, we controlled for secular changes in practice and artefactual changes due to regression to the mean. Selection bias is only an issue in the unlikely event that the population changed suddenly and substantially in contrast to the underlying trend and differentially from trends in the control. S1 Table shows that population characteristics maintained stable trends over the study period, suggesting that this is not an alternative explanation for our findings. Furthermore, we controlled for unknown confounding events coincident with the policy by including Scotland as a comparator. Our study is also based on a very large population with stable trends in the outcomes before and after the intervention; therefore, we are well powered to detect effects. Finally, the compulsory nature and large scale of the intervention again limits selection bias and increases both the internal and external validity of our results.

Our study has several limitations. First, it is possible that the observed changes in trends could have been due to other concurrent policies targeting these outcomes but that did not occur in the control population. Following a literature review, we found one such national policy: an “enhanced service” encouraging GPs to provide extra support for patients deemed at risk of unplanned admission to the hospital; however, this was introduced a year after the Act and only targeted 1 of our outcomes (emergency admissions) in which we did not see a change [ 21 ]. We also considered the fact that the Act included a broad range of changes alongside GP-led commissioning and that observed changes in trends might be due to other aspects of the reforms. However, most of the other changes were support structures for the changes to commissioning (such as accountability systems and services regulating specialist care providers) that would be considered integral to the intervention itself, or structural changes to public health and preventative services that are likely to have little direct impact on hospitalisations or specialist visits [ 2 , 4 ]. Second, smaller-scale effects on certain specialties or diagnoses may have been diluted by the scale of our data. However, as the first study of this nationwide policy, and given the government’s aim to address rising demands and treatment costs within the NHS as a whole [ 4 ], our goal was to examine the association between the policy and trends in specialist visits and hospitalisations. Third, while we have nearly 3 years of postintervention data, it is possible that some effects of GP-led commissioning have not yet become evident. For example, GPs may have chosen to invest more in preventative services, which can take several years to result in population-level reductions in disease. Finally, our study uses routine data that were not specifically created to answer this research question. However, we use the data in high-level aggregate analysis and only use final, rather than provisional, data, which are regarded as complete. Therefore, quarterly changes are unlikely to be due to issues such as data completeness or misclassification [ 22 ].

Following the introduction of the HSCA, the Department of Health (DH) called for research to evaluate its impact [ 23 ]. Nevertheless, initial proposals were rejected, and, while the DH has published an evaluation focussing on the processes of the reforms, we were unable to find any studies looking at the impact of this policy on hospital activity [ 23 , 24 ]. There have been studies of previous policies that handed greater budgetary responsibility to GPs in the UK and in Israel [ 25 – 32 ]. However, the results of these studies are mixed and difficult to interpret, as all used simple pre-post designs, which do not take into account underlying trends in hospitalisations or specialist visits, and they examined smaller policies, which were voluntary and subject to volunteer selection bias. The lack of control for underlying trends in these studies is particularly important because study groups often appear to have had unusually high referral rates prior to the intervention (partly because budget allocations based on existing referral rates incentivized practices to inflate referrals before becoming budget holders) [ 27 ]. Any reduction could therefore have simply been due to regression to the mean.

Our findings suggest that, on a national scale, the concerns raised around restrictions in access to specialist services and rationing of care have not been realised. However, the lack of decrease in hospitalisations and the unanticipated increase in specialist visits also suggest the theorised shift in care away from hospitals to less expensive community settings does not appear to have occurred and, if anything, the increase in specialist visits may have led to cost increases. There are a number of possible reasons why specialist visits and hospitalisations did not decrease. First, while CCGs intended to increase clinical involvement in commissioning, survey evidence suggests that some GPs do not feel fully engaged with their CCG [ 33 ]. For example, the majority of GPs are CCG members but do not have a formal role in the governing body, and this group reported much lower levels of influence and ownership than governing body members. A lack of engagement with members may mean that many GPs feel detached from their CCG and under little pressure to make cost savings or unable to influence the way local health services are managed [ 33 ]. Second, the financial incentive for CCGs to reduce costs and GPs to change referral patterns may have been too small or too indirect, and, while practice income may have increased by shifting some care from hospitals to community-based care provided by GPs, concerns about potential conflicts of interest could have discouraged this [ 7 ]. Finally, it is also possible that referrals to specialists were already appropriate prior to the intervention, resulting in little scope for further reduction. This is supported by evidence that variations in referral rates in the NHS are primarily explained by characteristics of the patient population and not factors affecting GP services [ 34 ].

The increase in specialist visits in our study was surprising and may be an unintended consequence of the policy. We identified annual data on NHS costs for outpatient specialist visits from an independent source ( S3 Fig ). This also appears to show an increase in costs, corroborating our findings regarding upward trends in specialist visits. One explanation might be that the new responsibility for managing budgets has inadvertently increased administrative workload for GPs, resulting in less time to see patients. Under such circumstances, GPs may reduce their threshold for referral to avoid missing a diagnosis. There is some existing evidence to suggest that increased workload and reduced consultation time is associated with increased referral rates [ 12 , 13 ], although other studies have shown no effect [ 35 ]. We considered decreasing GP numbers or increasing supply of specialists as other potential explanations for this finding. However, although there was a slight decrease in the number of full-time equivalent GPs (from 0.69 to 0.67 per 1,000 population) between 2009 and 2010, this does not coincide with the increase in specialist visits, and the number of GPs remained stable from 2010 and, in fact, increased back to 0.69 per 1,000 population in 2014 [ 36 ]. Number of specialists (full-time equivalent consultants) increased gradually over the study period from 0.67 per 1,000 population in 2009 to 0.76 per 1,000 population in 2014 and there was no deviation in this trend around the introduction of the HSCA [ 37 ].

In conclusion, we found no evidence that the introduction of GP-led commissioning in England was associated with a reduction in overall hospitalisations or specialist visits. In fact, there was an increase in specialist visits, which appears to have been paralleled by an increase in expenditure. This study begins to decipher the macro effects of these significant reforms to the organisation of NHS commissioning. However, many questions remain unanswered. Examples include the appropriateness of any change in rates of specialist visits and hospitalisations, the effect of this change on health outcomes, whether changes differed according to CCG and why, and the generalizability of our findings to other health systems. This study alone is unable to determine whether the HSCA can be regarded as a good or bad policy, and further research is needed to evaluate other important outcomes such as costs and quality of care. Nevertheless, in the context of similar findings from other large-scale health policy experiments [ 38 ], more effort may be needed to target specific costly or poorly evidenced practices (such as tonsillectomy, tympanostomy, or antibiotics prescribed for viral infections) rather than to count on broad, system-wide policy changes that often have unintended consequences.

Supporting information

S1 table. population characteristics of england and scotland, 2007–2014..

https://doi.org/10.1371/journal.pmed.1002427.s001

S2 Table. Trend changes in specialist visits and hospitalisations following the intervention in England versus Wales.

Coefficients for trend change are relative change in the slope gradient following the intervention. Trend change study versus control is the slope change in England over and above any change in Wales accounting for differences in baseline trends. All segmented regression models used log transformed Gaussian distribution.

https://doi.org/10.1371/journal.pmed.1002427.s002

S1 Fig. Time series of outpatient specialist visits in England and Wales.

Red o = England, blue x = Wales. Lines = deseasonalized linear trend. Vertical lines delineate the intervention phase (between quarter 2 [Q2] 2014 and Q2 2013).

https://doi.org/10.1371/journal.pmed.1002427.s003

S2 Fig. Time series of inpatient hospitalisations in England and Wales.

https://doi.org/10.1371/journal.pmed.1002427.s004

S3 Fig. National Health Service (NHS) reference costs.

https://doi.org/10.1371/journal.pmed.1002427.s005

S1 Text. Controlled interrupted time series model.

https://doi.org/10.1371/journal.pmed.1002427.s006

S1 Checklist. REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement.

https://doi.org/10.1371/journal.pmed.1002427.s007

S1 Protocol.

https://doi.org/10.1371/journal.pmed.1002427.s008

https://doi.org/10.1371/journal.pmed.1002427.s009

https://doi.org/10.1371/journal.pmed.1002427.s010

https://doi.org/10.1371/journal.pmed.1002427.s011

https://doi.org/10.1371/journal.pmed.1002427.s012

• 1. Ham C, Baird B, Gregory S, Jabbal J, Alderwick H. The NHS under the coalition government. Part one: NHS reform. The King's Fund, 2015.
• 2. Health and Social Care Act. Health and Social Care Act 2012 [Chapter 7]. Available from: http://www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_20120007_en.pdf .
• 3. NHS Commissioning Board. Clinical commissioning group governing body members: role outlines, attributes and skills. Guidance July. 2012.
• 4. Department of Health. Health and Social Care Act 2012: fact sheets. https://www.gov.uk/government/publications/health-and-social-care-act-2012-fact-sheets: 2012.
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• 7. National Audit Office. Managing conflicts of interest in NHS clinical commissioning groups. National Audit Office, 2015.
• 11. NHS England. Quality Premium: 2014/15 guidance for CCGs. 2014.
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• 15. Timmins N. Never Again? The story of the Health and Social Care Act 2012: A study in coalition government and policy making. The King's Fund and the Institute for Government, 2012.
• 16. Health and Social Care Information Centre. Hospital Episode Statistics: Health and Social Care Information Centre; [14th March 2016]. Available from: http://www.hscic.gov.uk/hes .
• 17. NHS Scotland Information Services Division. SMR Datasets [14th March 2016]. Available from: http://www.ndc.scot.nhs.uk/Data-Dictionary/SMR-Datasets/ .
• 18. Office for National Statistics. Population estimates [14th March 2016]. Available from: http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates .
• 19. Health and Social Care Information Centre. HES 2010–11 Outpatient Data Quality Note: Health and Social Care Information Centre; 2011. Available from: http://www.hscic.gov.uk/catalogue/PUB03032/host-outp-acti-2010-11-qual.pdf .
• 21. NHS England. Avoiding unplanned admissions enhanced service: Guidance and audit requirements 2014 [05/07/2014]. Available from: http://www.nhsemployers.org/~/media/Employers/Publications/Avoiding%20unplanned%20admissions%20guidance%202014-15.pdf .
• 22. Health and Social Care Information Centre. Hospital Episode Statistics (HES) Analysis Guide 2015. Available from: http://content.digital.nhs.uk/media/1592/HES-analysis-guide/pdf/HES_Analysis_Guide_Jan_2014.pdf .
• 24. Department of Health. Post-legislative assessment of the Health and Social Care Act 2012: Memorandum to the House of Commons Health Select Committee. In: Health Do, editor. 2014.
• 33. Robertson R, Ross S, Bennett L, Holder H, Gosling J, Curry N. Risk or reward? The changing role of CCGs in general practice. King's Fund and Nuffield Trust, 2015.
• 36. NHS Digital. General and Personal Medical Services, England September 2015—March 2016. 2016.
• 37. NHS Digital. NHS Workforce Statistics—September 2016, Provisional statistics 2016 [cited 2017 24/07/2017]. Available from: http://www.content.digital.nhs.uk/catalogue/PUB22716 .

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Health and Social Care Act 2012: fact sheets

These fact sheets explain particular topics associated with the act, including key themes. They include case studies of the policy in action and answers to frequently asked questions about the topic. The fact sheets were first published in October 2011 and have since been updated to reflect the changes made during the act’s passage through Parliament.

Was the Health and Social Care Act as bad as we thought?

The Health and Social Care Act 2012 set out the single biggest collection of reforms that the NHS had seen since its creation in 1948.

Focusing on patient-centred care, the legislation looked to improve quality and outcomes whilst reducing inequalities through clinically-led commissioning, but it was highly controversial and critics were quick to lambast it as a disaster .

With commentators scrutinising the act for a supposed erosion of the NHS’s core value - free universal provision at the point of delivery - nearly a decade later we ask: was it really as bad as we thought?

“ It cost billions of pounds and there were significant criticisms of its aims and impact, but the promotion and digitisation of healthcare is a legacy that has fundamentally shifted the NHS’s approach. ”

The biggest piece of legislation of its time

When the UK Government introduced the principles of the Health and Social Care Act in a 2010 white paper, its key aim was to modernise the NHS to meet rising demands, increased treatment costs and to decentralise health spending to specially-formed Clinical Commissioning Groups (CCGs). A crucial objective was to build sustainability for the future.

This was a substantial piece of legislation and it was bound to run into issues, not only because it worked towards the “transferring of public assets and revenue streams to public sector workers ”, but also because it was set to save billions per year in clunky administrative costs and shake-up healthcare management as we knew it.

What didn’t work?

Significant overspend.

In theory, the move towards clinically-led commissioning sounded positive - putting funding straight into the hands of those providing the services to use it how they best saw fit. This would mean that, for example, instead of going through a lengthy procurement process, CCGs could commission services directly for their communities with limited red tape.

However, not only did the proportion of CCGs reporting a budget deficit jump from 15% to 29% between 2016 and 2017, some reported deficits of up to £60m - totalling over £100,000 in excess spending per day. This was perhaps expected in part as non-specialists were now in charge of running the business side of healthcare, but had real impact on healthcare provision and decisions about what to fund or cut to balance the books.

Worsening health inequality

One of the Health and Social Care Act’s key aims was to reduce health inequalities across the entirety of England, primarily through the involvement of local authorities, who now had increased public health functions. This meant CCGs could respond to their specific geographical health concerns, for example to work on interventions to mitigate higher levels of child obesity rates and lung cancer prevalence in poorer areas of England.

However, best practice did not ensue across all 223 trusts. CCGs were responsible for the full financial risk , and research undertaken in 2016 showed that health inequalities were persisting with patchy success on the part of CCGs to reduce it. In fact, in September 2021, Health Secretary Sajid Javid admitted that the COVID-19 pandemic had laid bare underlying health inequalities in England, which is suffering from “the disease of disparity”.

What did work?

Local consultation.

In some ways, being able to target location-specific health needs by giving funding to those with the most on-the-ground insight was positive for many communities, and CCGs have been successful in some localities.

Hull CCG , for example, canvassed local people about their healthcare with a view to incorporating suggestions into their service offering. The CCG also appointed “patient ambassadors” who worked directly in the community and fed back patient voices on local interventions as time went on. This led to patient and community-centered service redesign and informed planning for new services.

The starting blocks for NHS Digital

NHS Digital - formerly the Health and Social Care Information Centre - was constructed on the back of the Health and Social Care Act 2012, and its establishment saw an overhaul in development and operation of digital technology and data services across the NHS in England. The rationale was that by having the right IT services in place, patients would get better care, and data could be used to further improve healthcare outcomes.

NHS Digital has been instrumental in creating technological infrastructure to keep the health service running and link systems together, publishing standards like the Data Security and Protection Toolkit, and using health and care data to improve understanding of health problems and support medical research.

Foundations for integrated care

The Health and Social Care Act also created the foundations for the 2021 Health and Care Bill, which will see the mandatory introduction of Integrated Care Systems (ICSs) across England. These Bill proposes a knitting together of local government, individual NHS trusts, and social care providers with the aim of created an integrated care framework that favours shared responsibility of health and care providers following years of patchwork care in the community. If voted through by parliament, ICSs could be mandated as early as 2022.

How successful was it on balance?

The Health and Social Care Act 2012 restructured the NHS. It cost billions of pounds and there were significant criticisms of its aims and impact, but the promotion and digitisation of healthcare is a legacy that has fundamentally shifted the NHS’s approach.

There were some leaps of progress catalysed by the act, but there is still a long way to go in ensuring best practice and minimum standards for making digital truly work for the NHS. Undoubtedly, the NHS is improving in both its approach and delivery of healthcare, becoming a more modern service, fit for the needs of a more diverse population with complex needs, but only time will tell whether the foundations built by 2012’s Health and Social Care Act are strong enough to support what comes next or will require multiple overhauls as time goes on.

If you want to hear direct from health and care leaders about what they think the NHS needs to do to make digital a working reality, why not sign up to our insights series, which has seen interviews with key figures from NHSX, The Royal Marsden, and more? Click here to sign up.

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Major 2012 NHS reform failed to deliver on promises, finds study

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The government’s major reorganisation of the health service in England in 2012, the most sweeping in the recent history of the NHS, failed to reduce admissions to hospital, shows a new study that tracked the effects of the changes on hospital workloads. Furthermore, it found an increase in outpatient visits to specialists after 2012.

The study, reported in PLOS Medicine , 1 looked at the effect of the Health and Social Care Act 2012, which introduced the clinical commissioning groups (CCGs) that gave greater control of secondary care budgets to GPs. Policy makers hoped that this would shift care away from hospitals to the community.

Using routinely collected hospital episode statistics, the researchers tracked trends in all NHS outpatient specialist visits and hospital admissions in England between 2007 and 2015. They compared these figures with those in Scotland, where there was no similar reorganisation, as a control.

Their results showed no significant change in trends in hospital admissions in either England or Scotland. The change in slope for total admissions was −0.2% (95% confidence interval −0.6% to 0.2%) a quarter in both countries.

However, numbers of outpatient appointments in England increased nearly four times faster after the reforms were introduced in 2012 than before, with an increase in total outpatient visits to specialists per quarter of 1.1% (0.7% to 1.5%) (P<0.001). This resulted in a 12.7% higher rate of specialist visits each quarter by the end of 2015, giving a total of 3.7 million additional specialist visits than would have been expected from the trend before the reforms. In contrast, there was no change in the rate of specialist visits in Scotland.

“Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits,” wrote the authors, led by James Lopez-Bernal, from the London School of Hygiene and Tropical Medicine.

Commenting on the findings, Nigel Edwards, chief executive of the health think tank the Nuffield Trust, said, “This calls into question the entire basis of using commissioning as a model to effect this type of change. The scheme was based on a false premise and was very unlikely to work. It is not very surprising the reforms didn’t have the effects expected.”

But Edwards cautioned that a major policy change of any type would take some time to show effects, so tracking hospital activity for only three years after the 2012 act might be insufficient. He added that Scotland may not have been a good comparator, as NHS Scotland introduced policy changes over the same period.

The researchers said, “The increase in specialist visits in our study was surprising and may be an unintended consequence of the [national] policy.” They suggested, “One explanation might be that the new responsibility for managing budgets has inadvertently increased administrative workload for GPs, resulting in less time to see patients. Under such circumstances, GPs may reduce their threshold for referral to avoid missing a diagnosis.”

They called for further research to establish the reasons for the increase in specialist visits after the 2012 reorganisation and suggested that other interventions might be needed to shift more care into the community.

• ↵ Lopez Bernal JA, Lu CY, Gasparrini A, et al. Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: a controlled interrupted time series analysis. PLoS Med 2017 ;( Nov ). doi:10.1371/journal.pmed.1002427 .

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The Health and Social Care Act 2012

Nicola glover-thomas.

University of Manchester, UK

Although the National Health Service (NHS) is regarded as a national treasure, it is no longer immune from the colossal financial pressures brought about by global recession. Economic sustainability has largely driven the reform process leading to the Health and Social Care Act (HSCA) 2012, however; other considerations have also played a role in the journey to turn the health and social care service into an institution which is fit for the 21st-century needs. This article examines the impact of the HSCA 2012 on those made vulnerable through mental ill health. It then considers three issues: First, whether parity between mental and physical health can have life beyond political rhetoric; second, what impact driving up efficiency within the NHS will have upon mental health patients; and finally, the extent to which the personalisation agenda can be meaningfully applied within the mental health context.

Introduction

Over the last 60 years, the National Health Service (NHS) has become an intrinsic feature of the United Kingdom, not only underpinning the nation’s health but exemplifying some of its core values and beliefs that are still widely held today. 1 The NHS was founded upon three core principles: to meet the needs of everyone; to remain free at the point of delivery and that access to the NHS be based on clinical need, rather than ability to pay. 2 These principles remain a fundamental part of the NHS – yet as the years have passed, there is broad agreement that modernisation of the NHS has become a necessity. 3 With costs soaring and demand rising exponentially; with the need for improvements and technological developments remaining an unremitting drain on the NHS coffers and the current economic climate making protected, ring-fenced NHS budgets unsustainable in the years to come, proactive steps to reform the NHS have been taken in the shape of the Health and Social Care Act (HSCA) 2012. 4 Modernisation has been driven by the demands placed upon a 60-year-old health service provider. Yet the drive to take the health service into the 21st century and become an economically viable and sustainable endeavour has also highlighted another deep-seated problem within the NHS: How to ensure vulnerable groups are cared for effectively, particularly with shifting demographics. The focus of this article is that of the mentally ill, and it will consider how this group fares under the changes introduced by the HSCA 2012.

Prior to the enactment of the HSCA 2012, the needs associated with mental health conditions 5 had already been explicitly acknowledged as a priority. 6 Since then, a new mental health outcomes strategy was published in February 2011, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages , 7 followed by an implementation framework, published in July 2012. 8 The strategy aims to provide better mental health for all and to increase the number of people recovering from mental health conditions, whilst the implementation framework focuses on the provision of strong outcomes monitoring. These mental health objectives are expected to map onto the broader NHS changes under the HSCA 2012 by virtue of explicit recognition within the legislation that mental ill health will be given parity alongside other physical health needs. 9 The consolidation of these steps by the HSCA 2012 is fundamental in ensuring mental health conditions are effectively recognised and responded to. 10 Achieving this will not be easy in a climate where the global burden of disease is rising, and mental health and behavioural disorders in particular account for an increasing proportion of this. 11 Provision for the mentally ill has always been stretched, struggling under the weight of systemic neglect and a lack of resources. The vulnerable, whether the mentally ill, the elderly or those who are mentally incapacitated, are particularly at risk as they are often not in a position to protect their own rights. Instead, reliance is placed upon those around them and the systems they are placed within to do this for them.

In the wake of the HSCA 2012, it is necessary to reflect upon whether the 2012 Act offers hope to those made vulnerable through mental ill health, or whether it instead fails them, and if so, why? This article explores this question with reference to three key policy drivers within the legislation and is structured accordingly. In the first instance, the article examines the HSCA 2012 from the mental health perspective, in terms of how the restructured commissioning process operates and how it maps on to the mental health framework. Attention is then given to three issues: First, whether parity between mental and physical health can in all reality have life beyond political rhetoric; second, what impact driving up efficiency within the NHS, in terms of commissioning decisions, will have upon patients with mental health conditions and third, the extent to which the personalisation agenda can be meaningfully applied within the mental health context. These issues are considered with reference to broader policy influences within the mental health law and policy landscape.

The HSCA 2012 – the mental health perspective

Whilst the fundamental restructuring of the NHS has been the subject of recent attention with the enactment of the HSCA 2012, mental health has also been under the spotlight of reform in the past few years. The Mental Health Act 2007 12 sought to respond to the challenges posed by changing psychiatric practices and the policy shift from hospital-based treatment to care in the community. 13 Over the last two decades, reliance on hospital-based care has diminished and has been replaced by the community as the dominant care environment. Hospital care is now reserved largely for those requiring acute or intensive psychiatric care. 14 To some extent resources have followed this changing pattern of care, but inevitably, service provision and delivery has been affected by the gradual shift in the mental health landscape. 15

In parallel with the introduction of the Mental Health Act 2007, modifications have been made to the Mental Health Act Code of Practice to reflect the legislative amendments. Whilst the Code is not legally binding, decision-makers are required to justify any departures from its guidance in their decision-making. 16 The amended Code features principles which are designed to promote patients’ interests and guide decision-making under the Act. 17 These principles are first, the purpose principle, whereby decisions under the Act must be made to minimise the undesirable effects of mental disorder; second, the least restriction principle, where decision-makers should keep to a minimum the restrictions they impose on the patient’s liberty; third, the respect principle, whereby recognition and respect should be given to the diverse needs, values and circumstances of each patient; fourth, the participation principle that encourages patients’ involvement and finally, the effectiveness, efficiency and equity principle that focuses upon optimal decision-making using available resources in the most efficient way possible. 18 In many ways, the essence of these principles can also be found within the HSCA 2012. However, whilst these principles promote universally recognised values and provide an opportunity to foster better care, their literal interpretation may not always ‘fit’ the actual process of implementation. It is often here where the legislative framework fails the mentally vulnerable. Ineffective implementation of core values within both ‘hard’ and ‘soft’ legal instruments is, perhaps, the largest source of damage for vulnerable groups and will be reflected upon throughout this article.

The HSCA 2012 has been heralded as the most extensive and radical reorganisation of the NHS to date 19 and has been accompanied by significant levels of political rhetoric, speculation and controversy. 20 The legislation had two key objectives: To improve the quality of care and outcomes for patients and to reposition the mode of provision so that health service provision becomes more patient-centred and facilitates choice. These objectives are incontrovertible; however, many of the mechanisms that the legislation introduces to achieve these aims have generated concern amongst service users, clinicians and service providers alike. The changes introduced by the Act are far reaching and for those with chronic and enduring conditions, of which all mental health conditions would likely be labelled, the HSCA 2012 can be expected to wield significant weight in treatment and care planning as it becomes fully operational in the months to come.

Several key elements of the legislation guide its implementation: ensuring a patient-centred NHS; promoting and supporting a clinician-led service and transferring the emphasis of measurement to clinical outcomes. 21 However, it is conceivable that these principles have the potential to conflict with significant consequences and may have lasting implications upon the quality of delivered care. The question remains whether any one of these principles will dominate during the implementation process, and if so, which it will be. The persistent concern amongst many professional and user groups 22 alike has been and continues to be that the political desire to make financial savings and improve the cost-effectiveness of the NHS may prove to be the overarching driver. 23 A related concern is that the legislation represents an inevitable shift away from the ideology of universal provision, a mainstay of the old NHS, 24 towards a stronger endorsement of expanding private sector involvement and a gradual privatisation of the health service. 25 The reinforcement of competition principles within the health care system is likely to have a detrimental impact on the mentally vulnerable as the Act opens up private sector involvement, making the process of commissioning outside of the NHS structure easier and more cost-effective. In all likelihood, this will encourage providers to be more active in lucrative areas of health care. Mental health care and associated social care provision is generally seen as an unprofitable field, with long-term and often complex care and support required by individuals. The 2012 Act’s market-based approach may prove to be particularly damaging for the mentally ill, with resources being allocated away from the needs of this group and short-term care measures, such as acute inpatient provision, being given greater attention than the longer term health and social care needs of individuals in the community. The Act also introduces a change to one of the central NHS tenets: 26 No longer will services be exclusively operated via the NHS and its partners; instead, ‘any willing provider’ could supply services. This enables the private sector to have direct access to the central operations of the NHS, in terms of both planning and provision. Although this allows for ‘any willing provider’ and thus goes beyond the private sector, social enterprises may find it difficult to compete against organisations in the private sector who can afford to undercut in the race to acquire a commissioning contract. 27 Currently, the role of third sector organisations in mental health care is much more prominent and is, indeed, essential, particularly in relation to social care provision; however, whether this will continue remains open to speculation. 28 If third sector organisations do struggle in this new provider landscape, the mentally ill will inevitably suffer as the tailored, personal provision currently offered by many small organisations and charities is likely to be curtailed as they battle to compete. 29

Commissioning of services for mental health care and treatment services will be conducted and guided by Clinical Commissioning Groups (CCGs), 30 which are introduced by the HSCA 2012, in a similar fashion as for all other services. The guiding principles 31 under the HSCA 2012 will be influential in how CCGs conduct their activities. In the first instance, CCGs have a duty to promote the NHS Constitution 32 and ensure patients, staff and the public are aware of the NHS Constitution and their NHS constitutional rights. CCGs will also have a general duty to improve the quality of the services they provide or commission. Primary medical services (which include acute inpatient psychiatric care and secure psychiatric units) are to be commissioned by NHS England. The focus on quality improvement goes beyond the old duty that primary care trusts (PCTs) had under NHS Act 2006, which was to improve the quality of health care services apropos existing published standards. Instead, the duty under the HSCA 2012 explicitly recognises the need to consider treatment and care outcomes and the patient experience. CCGs are also required to endorse a patient-centred approach 33 by encouraging patient involvement through shared decision-making. The implementation of this duty will be facilitated by new guidance to be published by NHS England. 34 As part of the focus upon patient-centred provision, CCGs will now also have to operate with a view to commissioning services from more than one provider as the 2012 Act also introduces a duty to enable patient choice.

How viable the balancing exercise of enabling patient choice within the mental health field will be remains to be seen. The creation of patient choice relies not only upon CCG behaviour endorsing and facilitating patient choice, but the providers of these services must actually exist – in mental health, the fulfilment of identified need has often presented challenges, as service provider limitations are routine. At a broader level, concern surrounds the impact this duty to facilitate patient choice may have on the market. 35 Encouraging CCGs to commission several alternative treatments from different providers may lead to more providers having a smaller market share and greater fragmentation within the health and social care service sector might result. 36 Quite how the commissioning process can effectively achieve efficiency through competition whilst also increasing patient choice is difficult to understand; or at least, it is possible to foresee challenges and tensions developing in the attainment of this aim. Patient choice is often determined through a plethora of motivating factors, not least the common desire to be close to family and friends. For many, access to psychological services is a central wish, with drug therapy being a necessity of last resort. However, as we will see later in this article, drug therapy is often deemed to offer a front-line response to patients’ mental health needs by general practitioners (GPs), and psychological services are limited in availability. 37 CCGs will be restricted by these practical limitations, but they will also be under a duty to ensure service commissioning is subject to tender under the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013. 38 If the framework of health and social care does crumble under the weight of these different legislative objectives, those with mental health conditions may be particularly vulnerable as a fragmented health and social care service will not be beneficial to them. Additional choice may inevitably be at the expense of effective integration.

Despite this, under the 2012 Act, CCGs have a duty to promote service integration. This entails the integration of health services with health-related and social care services. The political motivation behind this duty is to improve efficiency of service provision and to reduce unnecessary costs. Nonetheless, from the patient perspective, this offers an avenue for improvements in quality of life, particularly for those who need longer term support in the community. For the mentally vulnerable, effective integration of services is often particularly important, improving the implementation of treatment plans, medication compliance and ongoing community-based support. The difficulty with this duty is that as yet no guidance has been supplied to aid CCGs in the process of achieving good integration amongst and between these various services. Furthermore, mental health provision is littered with countless examples of joint working failures and inadequate communication throughout the health and social care system. Indeed, the ideal of achieving seamless provision is far removed from the reality for many patients, and it is often this which leads to the disjointed care that is received 39 and the gaps in provision where patients fall through the net.

The required establishment of Health and Wellbeing Boards 40 by each local authority may reduce the perennial problems surrounding joint working. 41 Collaboration between the Board members will afford the opportunity to assess local health and social care needs, agree on spending priorities and encourage CCGs to work with seamless, joined up provision in mind. Boards can extend their membership to reflect particular area needs; this may allow a local service to be developed for local needs. The Board is also required to take account of affiliated services with social care, such as, housing and education and to recognise that these services have a direct influence on the broader well-being of individuals. It is uncertain whether this will directly improve service provision, but the Cross-Government Mental Health Strategy 42 pins its hopes on the shift towards localism and local care decision-making under the 2012 Act. The Mental Health Strategy Implementation Framework 43 suggests that it is this focus on local needs which ‘can deliver the vision of improved mental health and wellbeing’. 44

The restructuring of the NHS and the changes created by the HSCA 2012 to the commissioning process will take time to grow accustomed to. From a mental health perspective, the HSCA 2012 offers real potential to see mental health brought from the margins of provision to feature much more prominently. It creates the possibility for a conceptual reconfiguration of health to emerge, introducing explicitly the need for parity between mental and physical health. Indeed, this duty to promote health parity could create the impetus for a paradigmatic shift within health and social care provision, but just how successful the implementation of this will be remains to be seen as the high-level commitment to health parity is only one of several key objectives within the 2012 legislation. Devolution of budgets down to CCGs may provide opportunities for mental health to feature more prominently within the commissioning process; yet there are concerns that mental health needs may continue to be overlooked by CCGs when pressure to commission services efficiently whilst also increasing patient choice presents significant tensions for CCGs to overcome.

We will now turn to consider three drivers within the 2012 Act, exploring whether they are feasible within the mental health context or whether the legislation will prove to be detrimental to those with mental health needs. First, attention will be given to the commitment to achieving parity of physical and mental health within the health care system, followed by a consideration of how the desire to increase efficiency may influence commissioning decisions within the mental health arena and finally, consideration will be given to the move towards expanding patient choice and personalisation within the health care market.

Parity between mental and physical health in the commissioning process: More than political rhetoric?

The Government’s draft mandate to NHS England is explicit in its message: Direct recognition is to be given to the need to place mental health on the same footing as physical health. 45 This is a significant step forward and should be welcomed. Mental health conditions are now to be recognised as a clear equality issue 46 and the NHS Equality Delivery System 47 will be primed to help those providing NHS services to respond properly to it. 48 Perhaps of greatest importance is the Government’s recognition in the Mental Health Implementation Framework 49 that achieving parity between physical and mental health is an absolute goal, 50 where more still needs to be done to ensure all organisations (both public and private) ‘meet their equality and inequality obligations in relation to mental health’. 51 Steps are being taken to create a framework to measure outcomes and overall progress within mental health, 52 so that improvement strategies can be created and implemented when clear underperformance is identified.

Clearly, making improvements for mental health provision is dependent upon good implementation. CCGs will be expected to demonstrate to NHS England that they have sufficient planned capacity and an ability to commission for improved health outcomes in mental health. Owing to this shift in attitude, and indeed, reconfiguration of the conception of health within the legislation, the neglected and under-resourced mental health service may be a thing of the past. The drive to improve access to psychological therapies for patients with mental health conditions is an example of this attitudinal shift and is a welcome move. 53 The rhetoric of achieving parity between mental and physical health is, in many ways, politically driven, though the evidence suggests that greater effort to improve mental health is needed; mental ill health is a leading cause of suffering, economic loss and social problems and accounts for over 15% of the disease burden in developed countries. 54 In the European Union at least 83 million people (27%) suffer from mental health problems (16.7 million in the United Kingdom), 55 with depression being the most common (8–12% of the adult population). 56

The newly restructured system of health and social care is in its infancy, and it is still too early to say whether the steps taken to achieve parity will bear fruit. Likewise, how the vulnerable will be able to protect their rights in this new health and social care environment is unknown, but it seems likely that CCGs, if motivated by market-driven policies, could lose sight of the particular needs of these vulnerable groups. In many ways, achieving parity is a deep-seated cultural issue and goes far deeper than surface-level implementation. Achieving parity needs fundamental attitudinal change at institutional, organisational and individual levels. For mental health, the best hope for this change exists within the Mental Health Implementation Framework 57 where explicit mention is made of the need to promote research into mental health and to recognise, support and strengthen academic career paths in this field. 58 It is only by consolidating capacity, instilling aspiration and professional motivation within the mental health care framework (both research and practice pathways) that the cultural transformation can begin to emerge.

Efficiency: The impact on mental health patients

Whilst parity of mental and physical health is a clear commitment within the HSCA 2012, the introduction of competition principles will also facilitate efficiency savings. Mental health needs are often complex, requiring the input of a variety of different agencies and service providers. Not only can providing for this complex diet of needs be difficult, it can be expensive. Both the cost and complexity of provision in mental health has been a persistent source of difficulty in the past and where tragic failures in care have occurred; investigations have often presented a catalogue of challenges surrounding the coordination and adequate funding of care. 59 Inevitably, establishing and identifying patient need and having the resources in place to meet it are not always achievable, and it is at this point that these system failures have often occurred. 60 The mental health care framework has very limited scope to be able to deal with increases in demand, and, traditionally, this is where the third sector has often been sought to plug the gap. 61 It is quite possible that without any form of overarching regional oversight, a task that PCTs undertook prior to the 2012 Act, the commissioning process may become fragmented and uncoordinated, and ultimately, gaps in some areas may be difficult to fill as patient needs may not be recognised in the round. 62

Two separate issues in the commissioning process for mental health services exist: First, the level of clinical expertise that exists and second, whether CCGs have sufficient management experience to meet the need for equal distribution and coverage of services. These two areas raise doubts about how efficient and effective commissioning decisions will be carried out. In the first instance, there are doubts concerning GPs’ broad clinical knowledge and expertise to identify and evaluate patient mental health needs. For many GPs, the initial response to patients presenting with mid to mild mental health conditions is to prescribe medication, rather than ‘approach treatment holistically and refer patients to psychological therapies, peer-to-peer support networks or community-based services’. 63 GPs often rely heavily upon drug therapy as the first response to symptomatic presentation in patients, 64 which adds to the sense that GPs lack the depth of knowledge necessary. This is supported by recent research which reported that 30% of patients found their GP was unaware of services to support mental health recovery beyond medication. 65 Second, it is predicted that CCGs may have inadequate management expertise and from this, optimal commissioning decisions will be less likely to occur. 66 Given the sheer scale of care and social support needs that patients with mental health conditions often need, if CCGs lack membership that reflects the level of experience needed to recognise this, adequate mental health care provision is likely to be inadequate.

If pockets of poor management do emerge, 67 then mental health provision may be adversely affected. Often mental health provision is not the focus, with greater attention being given to physical health needs; yet mental health conditions account for 23% of the total burden of disease; but in terms of NHS expenditure, only 13% of health expenditure is currently directed towards psychiatric and related services. 68 Such underinvestment is not new and despite funds being channelled through PCTs at a regional level to recognised areas of need prior to the HSCA 2012, resource shortfalls have been commonplace. Mental health did not gain the moniker of the ‘Cinderella’ service without good reason and has been struggling under the weight of systemic neglect for a considerable time. 69 Unfortunately, mental health care must compete with all other health and social care needs, of which most are far more evident and have a more tangible quality about them. Whether the HSCA 2012 will improve this is uncertain. Management inadequacies and failures to identify needs by CCGs may not be detected as there remains some doubt about how the new NHS structure and regulatory bodies will scrutinize and oversee activities. The organisational reconfiguration reflects the mood of the Government to reduce bureaucracy and complexity in the health and social care framework, to improve efficiency and to redeploy functions through bodies that are independent or at least operating at arm’s length of the Government. 70 Time will tell how these national bodies will work together in practice though as ‘it is … [just not yet] … clear how these national bodies will interact or how they will provide coordinated and consistent governance of the NHS’. 71

The challenges facing CCGs are unlikely to reassure patients in the short term; for mental health patients, these concerns may simply be more acute, given the complexity of typical mental health care needs which tend to stretch over a number of agencies and providers, often featuring periods of both acute need and stable chronicity. The standard and effectiveness of care received will all too often depend upon a strong framework of planned and integrated systems or pathways of care from a well-coordinated network of providers. CCGs are going to have to ensure sufficient awareness is present within the strategic planning process to take account of this, and if they do not, health conditions, including most mental health conditions, that require a complex health and social care response may suffer. The position of the already vulnerable could simply be compromised further.

Personalisation: Mapping the agenda on to the mental health framework

Personalisation is a central tenet of the restructured NHS. It refers to a social care approach where every person in need of care and treatment will have ‘choice and control over the shape of that support in all care settings’. 72 Personalisation is characterised by shifting the power dynamic within the provider–user relationship. Greater emphasis is placed upon self-directed support and personal budgetary control combined with a move away from the notion that provision should follow a ‘one-size-fits-all’ approach. 73

The personalisation agenda seeks to move the health and social care framework away from crisis management, 74 relying upon patients identifying personal needs and making appropriate care choices to meet these needs. 75 For this to be possible, adequate information and transparency within the system is essential. To implement the personalisation agenda, the social care system, in particular, will need to be sufficiently capacious to enable patient choice to be fully achievable. This means that CCGs have to take seriously the need to make and implement local commissioning decisions in a way that will enable genuine choices to be made. Commissioning will need to be multilayered and from a variety of providers; it will need to be possible to manipulate services so that tailor-made packages of care can be created for individual patients. In addition to the actual availability of services, steps must be taken to facilitate patients in the decision-making process. All patients, irrespective of age, capacity or support needs, should be aided as far as possible to ensure treatment and care choices are modified and are reflective of the patient’s wishes. 76

Within mental health, the essence of personalisation has been grounded in the mental health ‘recovery approach’. 77 This approach is focused upon the mental health patient being afforded the opportunity to determine his own life and to be offered the support required to be able to live as independently as possible. 78 Some patients with mental health conditions have already experienced personalisation. For some time, 79 self-directed support has been an operational feature of care in the community. The idea is founded upon flexibility, choice and control of social care funding and focuses upon giving eligible people an annual budget to spend on their own care, 80 based upon self-designed care plans. 81 For many, creating a care plan and then organising providers to meet these identified needs is a challenging task to undertake alone. In practice, patients are encouraged to work with clinicians and social care staff to facilitate implementation. 82 When a plan has been formulated, social care support can be obtained from a variety of sources, including statutory social services, the private sector, the voluntary sector, community groups, neighbours, family and friends. For those who need it, assistance in devising a care plan reflective of individual need is an essential element of the process; particularly as individual budgets are increasingly being used as a vehicle to combine several funding streams that many mental health patients may need to access in the community. Payment for local authority adult social care falls within the remit for individual budgets and include integrated community equipment services, disabled facilities grants, Supporting People for housing-related support, Access to Work and the Independent Living Fund. 83 Glendinning’s 84 research into the effectiveness of pilot schemes conducted by the Individual Budgets Evaluation Network demonstrates some promising results for patients, whereby clear benefits can be achieved through greater choice and control over funding. However, to enable mental health patients and other chronic patients with complex social care needs to benefit from this, better integration of services and a collective willingness to embrace choice needs to be fostered. 85

How successful the personalisation agenda and its implementation under the HSCA 2012 is, is perhaps best judged by assessing the benefits to patients that have flowed from this agenda. Existing research already indicates that the injection of choice and control over care options can be very positive for patients and carers alike. 86 However, there is also evidence suggesting some groups may not be experiencing these benefits, notably, patients with mental health conditions, patients with dementia and other capacity-reducing conditions. 87 Bureaucracy and cuts in social care spending are exacerbating the situation; patients who require significant levels of support in this process may find their experience of the personalisation agenda hampered. Other associated and recurrent problems exist within the mental health system, placing further strain on the achievement of the personalisation agenda. For example, staffing shortages and service scarcities often result in extensive waiting times and inadequate response rates. 88 As such, staffing challenges and the need for extra support by mental health patients to benefit from the personalisation agenda may in reality make this policy a largely spurious one with little practical substance.

The HSCA 2012 represents a significant departure from a culture of public service provision that we have become accustomed to, but does it fail the vulnerable, notably those with mental health care needs? The need to drive efficiency up, whilst also tailoring health and social care to individual patients is, perhaps, an impossible dilemma. 89 Making systems responsive to individual need also raises the spectre of cost and waste; meeting the 2012 Act’s expectations will be an exacting challenge and not for the faint-hearted. How mental health provision will fare in this new and uncharted landscape remains open; but, inevitably, it will face its own set of problems in the months to come. Does the 2012 Act fail the mentally vulnerable? Time will tell, though the tensions that exist between three of the key policy drivers within the legislation, the focus of this article, suggest that where there are pressure points and the vulnerable may ultimately experience the greatest detriment. Competition principles within the health and social care system may drive efficiency up. However, they cannot be responsive to the more nuanced needs of patients with chronic conditions, particularly where care needs bridge both health and social care and are often required for lengthy periods of time.

Perhaps, the brightest ray of hope should be the recognition that parity between mental and physical health will be a clear objective. 90 As with so many of these things, effective policy needs to be translated into a workable and user-friendly legal framework that can then be implemented. In mental health, it is the implementation stage that frequently presents the most significant challenge for decision-makers, with limitations in staffing, funding and social care placements creating bottlenecks in the system. Unless these practical hurdles can be overcome, the desire to forge a new and fairer culture within health and social care, where parity between mental and physical health is the accepted benchmark, will be a very difficult one to attain.

The HSCA 2012 offers a very real opportunity to enable mental health to be mainstreamed into core public health priorities. But, this relies upon a determination reminiscent of Aneurin Bevan, ‘The NHS will last as long as there are folk left with the faith to fight for it’. It can only be hoped that there are those prepared and willing to fight to ensure the needs of vulnerable groups, such as those with mental health conditions, are met and protected and that faith in the achievement of health and social care equality endures.

Acknowledgements

The author thanks Prof Robert Thomas and Prof Christopher Newdick for their insightful comments on an earlier draft of this article.

Funding: This work was supported by a British Academy Mid-Career Research Fellowship, for which the author wishes to express her thanks.

1 For a detailed discussion of the creation and foundation of the NHS, see, N. Timmins, The Five Giants: A Biography of the Welfare State (London, UK: HarperCollins, 2001).

2 Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx (accessed 2 August 2013). See also, T. Delamothe, ‘Founding Principles’, British Medical Journal , 336 (2008), p. 1216. For a more detailed consideration of the foundations of the NHS in 1948, see, M. Powell, ‘Granny’s Footsteps, Fractures and the Principles of the NHS’, Critical Social Policy 16 (1996), p. 27.

3 For example, A.C. Enthoven, & M. Eccles, ‘A Promising Start, But Fundamental Reform is Needed’, British Medical Journal 320 (2000), pp. 1329–1331.

4 There is little doubt that the NHS is facing considerable challenges today. If the NHS ‘[was]…performing at world-class levels, the NHS could save 5,000 more lives from cancer, and 2,000 more lives from respiratory diseases each year. Our population is aging, while the cost of advances in treatments and medicines add around £600 million of funding pressure to the NHS budget every year’, Department of Health, Pausing, Listening, Reflecting, Improving , Available at: http://healthandcare.dh.gov.uk/pausing-listening-reflecting-improving/ (accessed 20 August 2013).

5 Throughout this article the term ‘mental health condition’ is used to describe all mental disorders or illnesses that meet generally accepted criteria for clinical diagnosis.

6 See, Department of Health, Modernising Health and Social Services: National Priorities Guidance 1999/00–2001/02 (London, UK: Department of Health, 1998); Department of Health, Saving Lives: Our Healthier Nation , Cm 4386 (London, UK: HMSO, 5 July 1999); Department of Health, National Service Framework for Mental Health: Modern Standards and Service Models (London, UK: TSO, 8 February 2007).

7 Department of Health, No Health Without Mental Health A Cross-Government Mental Health Outcomes Strategy for People of All Ages (London, UK: TSO, February 2011). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf (accessed 2 August 2013).

8 See, Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point, No Health Without Mental Health: Implementation Framework , 24 July 2012. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf.pdf (accessed 25 July 2013).

9 See, Department of Health, The Mandate: A Mandate From the Government to the NHS Commissioning Board: April 2013 to March 2015 (London, UK: Department of Health, November 2012).

10 Different data sets highlight the need to recognise mental ill health as a fundamental concern, for example, see, N. Singleton, R. Bumpstead, M. O’Brien, A. Lee and H. Meltzer Psychiatric Morbidity Among Adults Living in Private Households, 2000 (London, UK: TSO, 2001); Royal College of Psychiatrists, Mental Health and Work (London, UK: Royal College of Psychiatrists, 2008); S. McManus, H. Meltzer, T. Brugha, P. Bebbington and R. Jenkins, Adult Psychiatric Morbidity in England 2007: Results of a Household Survey (London, UK: National Centre for Social Research, 2009).

11 See, C. Murray, et al., ‘UK Health Performance: Findings of the Global Burden of Disease Study 2010’, The Lancet , 381(9871) (2013), pp. 997–1020.

12 See, Report of the Expert Committee, Review of the Mental Health Act 1983 (London, UK: Department of Health, 1999); HM Government, Reforming the Mental Health Act: Part I: The New Legal Framework (London, UK: TSO, 2000), Cm 5016-I; see also, J.M. Laing, ‘Rights Versus Risk? Reform of the Mental Health Act 1983’ Medical Law Review 8(2) (2000), pp. 210–250; J. Peay, ‘Reform of the Mental Health Act 1983: Squandering and Opportunity?’, Journal of Mental Health Law 3 (2000), pp. 5–15.

13 D. Pilgrim, ‘New ‘Mental Health’ Legislation for England and Wales: Some Aspects of Consensus and Conflict’, Journal of Social Policy 36(1) (2007), pp. 79–95.

14 Inpatient facilities are now often not a place for therapeutic intervention, but instead are ‘crisis stabilisation centres’, see, A. Hill, ‘Mental Health Services in Crisis Over Staff Shortages: Exclusive : Royal College of Psychiatrists Warns Society will be Overwhelmed if Ministers Fail to Fill Gap’, The Guardian , Monday 20 June 2011.

15 G. Thornicroft and M. Tansella, ‘Components of a Modern Mental Health Service: A Pragmatic Balance of Community and Hospital Care. Overview of Systematic Evidence’, The British Journal of Psychiatry 185 (2004), pp. 283–290; P. Tyrer and S. Johnson, ‘Has the Closure of Psychiatric Beds Gone Too Far? Yes’, British Medical Journal 343 (2011), p. d7457; G. Thornicrift and M. Tansella, ‘The Balanced Care Model: The Case for Both Hospital and Community-Based Mental Healthcare’, The British Journal of Psychiatry 202 (2013), pp. 246–248.

16 R (Munjaz) v Mersey Care NHS Trust [2005] UKHL 58.

17 In 1998, the Richardson Committee proposed that the new mental health legislation should be rooted in legislative principles, see, Report of the Expert Committee, Review of the Mental Health Act 1983 (London, UK: Department of Health, 1999). Instead, the guiding principles can be found in the Code of Practice , instead of on the face of the Mental Health Act 2007 (see, House of Lords, House of Commons Joint Pre-Parliamentary Scrutiny Committee Report on the Draft Mental Health Bill (HL Paper 79(1), HC Paper 95(1), Session 2004–2005, at para 64. For an in-depth discussion, see, P. Fennell Mental Health: The New Law (Bristol: Jordans Publishing, 2007), p. 37.

18 Department of Health, Code of Practice: Mental Health Act 1983 (London, UK: The Stationery Office, 2008) at paras 1.2–1.6.

19 By July 2010, the White Paper, Equity and Excellence: Liberating the NHS , Cm. 7881, was published. Although progress of the Health and Social Care Bill was slowed with a ‘listening exercise’ between April and May 2011 for the Government to hear and take account of concerns raised about the Bill, the Bill received Royal Assent on the 27 March 2012.

20 N. Timmins, Never Again? The Story of the Health and Social Care Act 2012: A Study in Coalition Government and Policy Making (London, UK: The King’s Fund and the Institute for Government, 2012). See also, R. Taylor, God Bless the NHS (London, UK: Faber & Faber, 2013).

21 See, Department of Health, Equity and Excellence: Liberating the NHS , Cm. 7881 (London, UK: TSO, 2010).

22 See, D. Redding, ‘NHS Reforms: What do They Mean for Patients?’ Guardian Professional , Tuesday 3 April 2012.

23 Exponential spending on the NHS has occurred since it was established in 1948. In 2010/11, government expenditure was £121bn, see, R. Harker, NHS Funding and Expenditure (London, UK: House of Commons Library, SN/SG/724, 3 April 2012). See also, C. Naylor, M. Parsonage, D. McDaid, M. Knapp, M. Fossey and A. Galea, Long-Term Conditions and Mental Health. The Cost of Co-morbidities (London, UK: The King’s Fund, 2012).

24 E. Speed and J. Gabe, ‘The Health and Social Care Act for England 2012: The Extension of ‘New Professionalism’’, Critical Social Policy 33(3) (2013), pp. 564–574.

25 Currently, it is estimated that £1 of every £20 spent in the NHS goes to a non-NHS provider, see, Q&A: The NHS Shake-Up , 1 March 2013, Available at: http://www.bbc.co.uk/news/health-12177084 (accessed 25 July 2013).

26 R. Page, ‘The Attack on the British Welfare State-More Real Than Imagined? A Leveller’s Tale’, Critical Social Policy 15(44–45) (1995), pp. 220–228.

27 N. Curry, C. Mundle, F. Sheil and L. Weaks, The Voluntary and Community Sector in Health: Implications of the Proposed NHS Reforms (London, UK: The King’s Fund, 2011).

28 N. Glover Thomas and W. Barr, ‘Re-Examining the Benefits of Charitable Involvement in Housing the Mentally Vulnerable’, Northern Ireland Legal Quarterly 59(2) (2008), pp. 177–200; N. Glover Thomas and W. Barr, ‘Enabling or Disabling? Increasing Involvement of Charities in Social Housing’, The Conveyancer and Property Lawyer 3 (2009), pp. 209–235.

29 Opening up markets creates considerable barriers to market entry by social enterprises as high capital costs can often only be found by large providers. As social enterprises are usually quite small (and so, there is a greater risk of failure to deliver the contract owing to shortages of funds) and there is no longer preferential treatment given to social enterprises, it is likely that in the health sector where social enterprises are competing with large NHS providers and private organisations, their involvement may diminish. See further, M. Brown and D. Floyd, Better Mental Health in a Bigger Society? (London, UK: The Mental Health Providers Forum, 2011).

30 CCGs are clinically led groups that include all of the general practitioner (GP) groups in their geographical area and have the aim of giving GPs and other clinicians the power to influence commissioning decisions for their patients.

31 Same as fn 19.

32 Section 3 of the Health and Social Care Act 2012 inserts a new section 1B into the NHS Act 2006, placing a duty on the Secretary of State to have regard to the NHS Constitution. Section 14P imposes a duty upon CCGs both to act in the exercise of its functions with a view to ensuring health services are provided in a way that promotes the NHS Constitution.

33 For a broader discussion, see A. Coulter, ‘Do Patients Want a Choice and Does it Work?’, British Medical Journal 341 (2010), p. c4989; Care Quality Commission, National NHS Patient Survey Programme: Survey of Adult Inpatients 2010; Survey of Adult Outpatients 2009; Maternity Survey 2010; Survey of Local Health Services 2008 . Available at: www.nhssurveys.org (accessed 31 August 2013); N. Richards and A. Coulter, Is the NHS Becoming More Patient-Centred? (London, UK: Picker Institute Europe, Department of Health, 2007).

34 NHS England, Developing the NHS Commissioning Board (London, UK: TSO, 2011), p. 9.

35 The National Health Service (Procurement, Patient Choice and Competition) Regulations 2013, No. 257, impose a requirement on the NHS Commissioning Board and clinical commissioning groups to protect patients’ rights to make choices and to prevent anti-competitive behaviour.

36 Care Quality Commission, The State of Health Care and Adult Social Care in England in 2011/12 (London, UK: TSO, 2012).

37 Cf. fn 64.

38 Same as fn. 35.

39 C. Ham and N. Walsh, Making Integrated Care Happen. Lessons From Experience (London, UK: The King’s Fund, 2013).

40 These Boards will take on their statutory functions from April 2013. See, Department of Health A Short Guide to Health and Wellbeing Boards . Available at: http://healthandcare.dh.gov.uk/hwb-guide/ (accessed 28 February 2012).

41 R. Humphries, A. Galea, L. Sonola and C. Mundle, Health and Wellbeing Boards: System Leaders or Talking Shops? (London, UK: The King’s Fund, 2012).

42 See, N. Glover Thomas, ‘Joint Working; Reality or Rhetoric in Housing the Mentally Vulnerable?’ Journal of Social Welfare and Family Law 29(3–4) (2007), p. 217.

43 Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point No Health Without Mental Health: Implementation Framework. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf . Briefing paper available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/137645/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf .

44 ‘Centre for Mental Health, Department of Health’ p. 5.

45 The first NHS Mandate was published on 13 November 2012. It sets out the Government’s ambitions for the health service until 2014 and reaffirms its commitment to an NHS that remains comprehensive and universal. Available at: http://mandate.dh.gov.uk/

46 An integral principle running through No Health Without Mental Health: Implementation Framework , is the acknowledgement that groups protected by the Equality Act 2010 need to be identified and protected. These groups are defined by the characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation. Parity of physical and mental health has been formally recognised as an important objective within health provision for many years prior to the HSCA 2012. This was acknowledged in the House of Lords Committee Stage debate where Baroness Hollins (Crossbench) moved an amendment to replace the word ‘illness’ within the Health and Social Care Bill with the words ‘physical and mental illness’. Lord Howe noted that the term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. He went on to note that ‘references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words’ (HL Hansard, 2 November 2011, col 1293).

47 The Equality Delivery System for the NHS was introduced in August 2011.

48 NHS services must explicitly consider the particular needs of the most vulnerable groups, and within this, mental health needs must be directly responded to.

49 Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point No Health Without Mental Health: Implementation Framework . Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf . Briefing paper available at: http://www.nhsconfed.org/Publications/Documents/mhn-briefing-247.pdf (accessed 17 January 2014).

50 Section 1 Health and Social Care Act 2012 emphasises the importance of mental health alongside physical health as it amends Section 1 of the NHS Act 2006, which contains the Secretary of State’s duty to promote a comprehensive health service designed to secure improvement in the physical and mental health of the people of England, and in the prevention, diagnosis and treatment of mental and physical illness.

51 ‘Health and Social Care Act’ fn 49, p 8.

52 ‘Health and Social Care Act’ fn 49. The mental health framework introduces a new mental health dashboard, which will provide a picture of overall progress towards implementing the mental health strategy.

53 Improving Access to Psychological Therapies (IAPT) is an NHS programme being rolled out across England offering interventions approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety disorders. The programme’s second phase is marked by the publication of Talking Therapies: a four year plan of action in February 2011. The plan aims to expand the scope of the programme to other groups, including, children and young people, people with long-term physical conditions and medically unexplained symptoms or severe mental illness. In the 2010 Spending Review, the Government committed an additional £400 million over the next 4 years to 2014/15, and confirmed support for the IAPT programme, which was originally launched in October 2008.

54 M. Prince, V. Patel, S. Saxena, M. Maj, J. Maselko, M. Phillips and A. Rahman. ‘No Health Without Mental Health’, Lancet 370 (2007), pp. 859–877.

55 H. Wittchen and F. Jacobi, ‘Size and Burden of Mental Disorders in Europe: A Critical Appraisal of 27 Studies’, European Neuropsychopharmacology 15(14) (2005), pp. 357–376.

56 T. Ustun, J. Ayuso–Mateos, S. Chatterji, C. Mathers and C. Murray, ‘Global Burden of Depressive Disorders in the Year 2000’, British Journal of Psychiatry 184 (2004), pp. 386–392.

57 Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point, No Health Without Mental Health: Implementation Framework , 24 July 2012. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf (accessed 17 January 2014).

58 E. Cyhlarova, A. McCulloch, P. McGuffin and T. Wykes, Economic Burden of Mental Illness Cannot be Tackled Without Research Investment (London, UK: Mental Health Foundation, 2010).

59 J. Ritchie, The Report of the Inquiry Into the Care and Treatment of Christopher Clunis (London, UK: Stationary Office, 1994); J. Coid, ‘The Christopher Clunis Enquiry’, Psychiatric Bulletin 18 (1994), pp. 449–452. See also, J. Manthorpe and N. Stanley, The Age of the Inquiry: Learning and Blaming in Health and Social Care (Oxford, UK: Routledge, 2004), chapter 7; N. Glover Thomas, ‘Joint Working; Reality or Rhetoric in Housing the Mentally Vulnerable?’, Journal of Social Welfare and Family Law , 29(3–4) (2007), pp. 217–233 and N. Glover-Thomas, An Investigation into Initial Institutional and Individual Responses to the Mental Health Act 2007: Its Impact on Perceived Patient Risk Profiles and Responding Decision-Making , Mersey Care NHS Trust Final Research Report, March 2011, pp. 1–158.

60 For example, the National Inquiry found in July 2013 that there were ‘1,508 suicides in patients under crisis resolution/home treatment teams (CR/HT), 12% of the total sample, an average of 137 deaths per year. Since 2006, there have been 150-200 suicides per year under CR/HT’. It was also noted that ‘since 2006 there have been more patient suicides under CR/HT than in in-patient care, reflecting a change in the nature of acute care [my emphasis]. In the last 3 years over twice as many suicides have occurred under CR/HT’; see, L. Appleby, N. Kapur, J. Shaw, I.M. Hunt, D. While, S. Flynn, K. Windfuhr and A. Williams. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report: England, Northern Ireland, Scotland and Wales (Manchester, UK: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Centre for Mental Health and Risk, July 2013), p. 31.

61 N. Glover Thomas and W. Barr, ‘Re-examining the Benefits of Charitable Involvement in Housing the Mentally Vulnerable, Northern Ireland Legal Quarterly 59(2) (2008), pp. 177–200; N. Glover Thomas and W. Barr, ‘Enabling or Disabling? Increasing Involvement of Charities in Social Housing’, The Conveyancer and Property Lawyer 3 (2009), pp. 209–235.

62 R. Millar, I. Snelling and H. Brown, Liberating the NHS: Orders of Change? Policy paper 11, Birmingham, UK: Health Services Management Centre, University of Birmingham, 2011.

63 All Party Parliamentary Group on Mental Health, Health and Social Care Reform: Making it work for mental health , 2011, p 8. Available at: http://www.mind.org.uk/assets/0001/8974/APPGMH_Report_Health_and_Social_Care_Reform_Making_it_work_for_Mental_Health.pdf (accessed 25 July 2013).

64 For example, ‘GPs prescribe soaring numbers of drugs for depression’, The Telegraph , Thursday 09 May 2013; Spence, D, ‘Are antidepressants overprescribed? Yes’, British Medical Journal , 2013, p. 346.

65 In an unpublished survey conducted by Mind in May 2011, of 1,237 mental health service users, 358 (28.9 per cent) of participants reported that their GP was unaware of services to support mental health recovery. Available at: http://www.mind.org.uk/news/5247_as_gps_leave_mental_health_patients_in_the_dark_mind_hits_the_road_to_champion_local_services#research (accessed 25 July 2013).

66 A. O’Dowd, ‘GP Consortiums Will Need First Class Management Support, says Nuffield Trust’, British Medical Journal 342 (2011), p. 342. Available at: http://www.bmj.com/content/342/bmj.d337 (accessed 17 January 2014).

67 Care Quality Commission, The State of Health Care and Adult Social Care in England in 2011/12 (London, UK: TSO, 2012).

68 The Centre for Economic Performance’s Mental Health Policy Group, How Mental Illness Loses Out in the NHS (London, UK: Mental Health Policy Group, 2012).

69 For in interesting discussion, see, J. Adams, ‘Challenge and Change in a Cinderella Service’: A History of Fulbourn Hospital, Cambridgeshire, 1953–1995, PhD thesis, The Open University, 2009.

70 See, Department of Health, Liberating the NHS: Report of the Arm’s- length body review (July 2010) Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117691 (accessed 3 August 2013).

71 K. Walshe & C. Ham, ‘Can the Government’s Proposals for NHS Reform be Made to Work?’, British Medical Journal 342 (2011), p. d2038.

72 J. Dunning, ‘Expert Guide to Personalisation’, Community Care . Available at: http://www.communitycare.co.uk/articles/25/07/2012/109083/personalisation.htm (accessed 25 July 2012).

73 A personal budget focuses upon providing ongoing social care support. See, Association of Directors of Adult Social Services Making Progress with Putting People First: Self- Directed Support (London, UK: DH/ADASS/IDeA/LGA, 2009a).

74 Department of Health, Caring for Our Future: Reforming Care and Support , Cm 8378 (London, UK: TSO, 2012).

75 R. Forster and J. Gabe, ‘Voice or Choice? Patient and Public Involvement in the National Health Service in England under New Labour’, International Journal of Health Services 38(2) (2008), pp. 333–356. See also, M. Fotaki, M. Roland, A. Boyd, R. McDonald, R. Scheaff and L. Smith, ‘What Benefits Will Choice Bring to Patients? Literature Review and Assessment of Implications’, Journal of Health Services Research & Policy 13(3) (2008), pp. 178–184.

76 S. Carr, Personalisation: A Rough Guide (London, UK: Social Care Institute for Excellence, 2012), p. 2.

77 See, L. Davidson, ‘Recovery, Self Management and the Expert Patient: Changing the Culture of Mental Health from a UK Perspective’, Journal of Mental Health 14(1) (2005), pp. 25–35.

78 S. Carr, ‘Personalisation: An Introduction for Mental Health Social Workers’, in P. Gilbert, ed., The Value of Everything: Social Work and its Importance in the Field of Mental Health (London, UK: Jessica Kingsley, 2010).

79 Department of Health, Independence, Choice and Risk: A Guide to Best Practice in Supported Decision-Making Executive Summary (London, UK: Department of Health, 2007). See also, Department of Health, Putting People First – Working to Make it Happen: Adult Social Care Workforce Strategy – Interim Statement (London, UK: Department of Health, 2008).

80 In March 2012, the Association of Directors of Adult Social Services Personal Budgets Survey showed that the total number of personal budgets delivered by local authorities across England is estimated to be 432,349, which is an increase of 38% in 2010–2011. The amount spent on personal budgets in 2011–2012 was nearly £2.6 billion some 15% of all direct spend on adult care and support services, ADASS, Personal Budgets Survey March 2012: Results (London, UK: ADASS/Judgement Framework, 2012).

81 ADASS, Making Progress with Putting People First: Self- Directed Support (London, UK: DH/ADASS/IDeA/LGA, 2009), see pages 3–4; See also, ADASS, Personalisation and the Law: Implementing Putting People First in the Current Legal Framework (London, DH/ADASS, 2009).

82 See, Putting People First Consortium Advice Note (January 2010): Personal Budgets: Council Commissioned Services (London, UK: Department of Health, 2010); Putting People First Consortium, Briefing Note (January 2010): Personal Budgets: Managed Services (London, UK: Department of Health, 2010); Putting People First Consortium The Future of Social Work in Adult Social Services in England: Statement (London, UK: Putting People First consortium, 2010).

83 Social Care Institute for Excellence (in collaboration with the AMHP National Leads Network and the Social Care Strategic Network for mental health), Personalisation Briefing: Implications for Community Mental Health Services (London, UK: SCIE, 2009).

84 C. Glendinning, The National Evaluation of the Individual Budgets Pilot Programme (York, UK: SPRU, University of York, 2008); C. Glendinning, H. Arksey, K. Jones, N. Moran, A. Netten and P. Rabiee, The Individual Budgets Pilot Projects: Impact and Outcomes for Carers (York, UK: Social Policy Research Unit, 2009).

85 N. Moran, C. Glendinning, M. Stevens, J. Manthorpe, S. Jacobs, M. Wilberforce, M. Knapp, D. Challis, J-L. Fernadez, K. Jones and A. Netten. ‘Joining Up Government by Integrating Funding Streams? The Experiences of the Individual Budget Pilot Projects for Older and Disabled People in England’, International Journal of Public Administration 34(4) (2011), pp. 232–243.

86 C. Glendinning, The National Evaluation of the Individual Budgets Pilot Programme (York, UK: SPRU, University of York, 2008).

87 Association of Directors of Adult Social Services, Personal Budgets Survey March 2011, Available at: http://www.thinklocalactpersonal.org.uk/_library/ADASS_Personal_Budgets_Survey_March_2011_-Summary_of_Results_9.6.11_3.pdf ; Think Local, Act Personal Partnership, Personal Budgets Outcome Evaluation Tool (Poet) Survey, June 2011. Available at: www.thinklocalactpersonal.org.uk (accessed 23 June 2013).

88 See for example, R. Kakuma, H. Minas, N. van Ginneken, M. Dal Poz, K. Desiraju, J. Morris, S. Saxena and R. Scheffler. ‘Human Resources for Mental Health Care: Current Situation and Strategies for Action’, The Lancet 378(9803) (2011), pp. 1654–1663; G. Aarons and A. Sawitzky, Organizational Climate Partially Mediates the Effect of Culture on Work Attitudes and Staff Turnover in Mental Health Services, Administration and Policy in Mental Health and Mental Health Services Research 33(3) (2006), pp. 289–301.

89 A. Woolridge, A. Morrissey and P. Phillips, ‘The Development of Strategic and Tactical Tools, Using Systems Analysis, for Waste Management in Large Complex Organisations: A Case Study in UK Healthcare Waste’, Resources, Conservation and Recycling 44(2) (2005), pp. 115–137.

90 P. Cunningham, ‘Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care’, Health Affairs 28(3) (2009), pp. 490–501.

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• Volume 9, Issue 4
• Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening
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• Jonathan Hammond 1 , 2 , 3 ,
• Thomas Mason 1 , 2 , 3 , 4 ,
• Matt Sutton 1 , 2 , 3 ,
• Alex Hall 2 , 5 ,
• Nicholas Mays 6 ,
• Anna Coleman 1 , 2 , 3 ,
• Pauline Allen 7 ,
• Lynsey Warwick-Giles 1 , 2 , 3 ,
• Kath Checkland 1 , 2 , 3
• 1 Division of Population Health, Health Services Research, and Primary Care , University of Manchester , Manchester , UK
• 2 School of Health Sciences , University of Manchester , Manchester , UK
• 3 Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
• 4 Manchester Centre for Health Economics , University of Manchester , Manchester , UK
• 5 Division of Nursing, Midwifery and Social Work , University of Manchester , Manchester , UK
• 6 Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
• 7 Health Services Research Unit , London , UK
• Correspondence to Dr Jonathan Hammond; jonathan.hammond{at}manchester.ac.uk

Objectives Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms.

Methods Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25–64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome—unassisted birth rates—largely unaffected by HSCA changes.

Results Interviewees identified that cervical screening commissioning and provision was more complex and ‘fragmented’, with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups.

Conclusions Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.

• health policy
• health system reform
• mixed methods
• commissioning

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2018-024156

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Strengths and limitations of this study

Few studies have investigated in detail the impacts of large-scale health system change.

This study combines detailed qualitative data exploring impacts on the system with quantitative exploration of important outcomes, supporting causal inference.

Based on qualitative findings, we developed a quantitative measure for assessing the extent of disruption to the English NHS commissioning system as a result of the 2012 Health and Social Care Act.

We found that cervical screening rates decreased more post-Act in areas that had experienced higher levels of disruption.

Introduction  

Structural reorganisations of publicly financed healthcare systems, driven by central government or other state agencies, are frequently employed with the objective of improving healthcare delivery, and thus population health outcomes, while reducing or containing costs. 1 However, such endeavours can be disruptive and expensive. 2 It is important to understand what possible impacts these reorganisations have in order to understand their value. 3

In the English National Health Service (NHS), attempts to evaluate the impact of reorganisations have typically used operational indicators (eg, bed availability, number of staff) and measures of clinical activity because their improvement was the stated goal of government policy (eg, The NHS Plan 4 ). Other studies have attempted to assess the impacts of reforms by measuring their effects on prices, quality and quantity of provision. 5 Most studies have relied on quantitative analysis of measures that were explicitly targeted by policy reforms. There is a need for approaches which combine qualitative and quantitative methods to generate a deeper understanding of the impacts of structural reorganisation. 6

The most recent structural reorganisation of the English NHS, the Health and Social Care Act 7 (hereafter ‘HSCA’ or ‘the Act’), was introduced in April 2013 and included wide-ranging changes to the health services commissioning system. We explore whether changes to the commissioning of cervical screening services resulting from the Act affected uptake. This analysis uses a relatively novel mixed methods approach. An initial ‘bottom-up’ qualitative analysis allowed us to identify problematic issues associated with the HSCA for those working locally in the health service commissioning system. This process highlighted the disruption to established commissioning arrangements and cervical screening as a clinical activity, which may be specifically affected by this disruption. We then developed a quantitative investigation to explore this more fully. Together these analyses allow us to infer causation.

The HSCA and changes to cervical screening commissioning

The HSCA is regarded as one of the most wide-ranging legislative reforms in the history of the English NHS. 8  Primary Care Trusts (PCTs), 152 organisations previously responsible for the commissioning of primary, community and secondary health services from providers on behalf of local populations, were abolished. Their commissioning functions were split between three groups of organisations: 211 (now 195) newly created Clinical Commissioning Groups (CCGs), membership organisations constituted by general practitioner (GP) (family doctor) practices, given responsibility for commissioning services for their local populations; NHS England (NHSE), a new arm’s-length governmental body with responsibility for authorising and assessing CCGs and commissioning some services at a national level; and top-tier and single-tier elected local authorities, which took responsibility for the majority of public health services for the first time since 1974. In addition, Public Health England (PHE) was created as an executive agency of the Department of Health, to unify the diverse public health profession and provide expert support for local public health services.

In some service areas, the transfer of commissioning responsibilities was relatively straightforward (eg, the commissioning of routine orthopaedic surgery was passed from PCTs to CCGs with minimal alteration to the bundle of services involved). In other service areas, the transfers were much more complex, particularly the commissioning of national screening programmes and sexual health services, as a result of changes to public health commissioning. Pre-HSCA, national screening programmes and sexual health services were both commissioned by PCTs. Cervical screening was largely provided by GP practices, which received additional funding linked to levels of activity, 9 but some women opted to have their cervical smears in PCT-commissioned sexual health clinics. Post-HSCA, responsibility for public health services, including most sexual health services, was transferred to local authorities. The underlying programme theory (ie, the explicit expectation about how the policy would work 10 ) was that local authorities would be better placed to address the wider determinants of health and well-being than the NHS because they could link public health services with their existing responsibilities, such as for transport and housing. 11 NHSE took responsibility for commissioning national screening programmes. 8 NHSE’s regional teams are responsible for commissioning screening programmes, supported by PHE staff ‘embedded’ within NHSE’s screening and immunisation teams. 12 There was no identifiable underlying programme theory for this specific change to screening programme commissioning. However, it is notable that, in contrast to the emphasis placed on localism associated with the creation of CCGs and with the transfer of public health to local authorities, screening commissioning became more centralised as a consequence of the HSCA.

Table 1 shows the organisations with responsibilities of relevance to the commissioning of sexual health, including cervical cancer screening services, pre-HSCA and post-HSCA. It illustrates how responsibility for such services, previously commissioned by PCTs, was split between different agencies. This increased complexity and fragmentation of responsibilities had the potential to disrupt service commissioning. 13

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Organisations of significance to the commissioning of cervical screening pre-HSCA and post-HSCA

This analysis comes from a study designed to foster emergent interplay between qualitative and quantitative data analysis. 14 15 The focus on cervical screening was not established at the project design stage but driven by the initial qualitative interview findings related to sexual health commissioning arrangements and screening activity post-HSCA. These findings prompted us to consider a quantitative exploration of predictions made by interviewees relating to potential changes in cervical screening activity.

Study context and design

This analysis forms part of a longitudinal project, with data collected between January 2015 and December 2017, into the effect of the HSCA on the commissioning system in England. We combined a qualitative and quantitative exploration of the commissioning of services in two large, socioeconomically diverse metropolitan areas of England with a national level quantitative study of commissioning outcomes. We used a sequential mixed methods approach in which initial qualitative data collection and analysis were used to shape an ensuing quantitative analysis using routinely available data. We therefore present the qualitative and quantitative methods and findings in the order undertaken, and integrate them in the ’Discussion' section.

Patient and public involvement

Our interest in exploring the impact of systemic commissioning change on cervical screening rates was driven initially by concerns expressed by interviewees about potentially negative consequences for patients relating to new arrangements. Patients were not directly involved in the design of, or recruitment to, the overarching project, but an advisory group including a patient representative met regularly throughout the project and played an important role in supporting its development. We presented our initial qualitative findings relating to cervical screening, and early ideas for developing a mixed methods investigation, to our advisory group and were encouraged by our patient representative to pursue this. The results of the broader project were disseminated to participants, and the advisory group, in the form of a series of short reports focusing on specific areas of commissioning and the final report.

Qualitative component

Setting, participants, sampling and data collection.

The qualitative component took place between March 2015 and August 2017, focussing on two metropolitan ‘health economies’ covering a geographical population and a group of commissioning organisations and providers with close operational links. Across both areas, we conducted 143 interviews (each typically an hour in length), 93 of which related to sexual health commissioning, with clinical and non-clinical commissioners, managers, clinicians and senior administrative staff from CCGs, local authorities, service providers and third sector organisations. Organisations and participants were sampled purposively for variation in type and role. We identified participants through organisational websites, personal contacts and through ‘snowballing’ in which we asked participants to recommend other potential participants. Additionally, 8 hours of meetings of an interorganisational sexual health coordinating group involving sexual health commissioners and providers were observed in one of the areas.

Interviews focused on the commissioning system pre-HSCA and post-HSCA, exploring continuities and changes to personal and organisational roles, key issues and challenges, accountability and performance management, interorganisational relationships and communication and commissioning decision-making. Interviews took place either in person (usually in participants’ offices) or over the telephone. All interviews were audio-recorded and all interviewees were provided with written information about the study before consenting to participate.

Data analysis

Audio recordings of interviews were transcribed verbatim, and observational notes from meetings were produced contemporaneously. Transcripts and observational notes were imported into NVivo V.10 software and analysed thematically by JH and AH. 16 This involved repeated readings of transcripts to become sufficiently familiar with their contents, identifying initial codes and coding chunks of data, searching for themes and then iteratively defining and reconstituting themes. Our findings (see below) contained some predictions made by participants regarding changes in cervical screening activity as a consequence of the Act. This prompted us to explore these predictions in a quantitative analysis, which we now describe.

Quantitative component

Interviewees identified that the HSCA had introduced confusion over responsibility for the commissioning of cervical screening services, and had increased variability of provision. They hypothesised that cervical screening rates might be reduced by the new commissioning arrangements; this prompted discussions among the research team and advisory group about developing a way of testing these predictions quantitatively as far as routine data would permit. As the Act had been implemented in all areas simultaneously, removing the scope for a quasi-experimental approach, we sought to identify a measure of variability in the extent to which the Act would have been expected to make commissioning more difficult in each area. One of the features of the post-HSCA system was that some, but not all, CCGs were established which crossed local authority boundaries. Some CCGs related to as many as three separate local authorities. Local authorities were now directly involved in sexual health services commissioning. Findings revealed that CCGs experienced extra challenges when they had to engage with more than one local authority. This suggested that the burden of additional interorganisational coordination might have consequences for commissioning.

As each local authority developed its own approach to cervical screening in its local sexual health clinics, we explored the possibility that GP practices located in CCGs which had to work with more than one local authority might experience lower screening rates compared with practices located in CCGs which had only to deal with one local authority. We compare the demographic characteristics of these two groups in table 2 . The 89 CCGs dealing with more than one local authority had a slightly older population profile than the 119 CCGs which dealt with only one local authority but were otherwise highly comparable.

Clinical Commissioning Group (CCG) demographic characteristics depending on the number of local authorities that the CCG needs to work with

Because cervical screening rates may be influenced by other factors that we cannot observe and may change over time in different ways between the two groups of CCGs, we also compared screening rates with an outcome that was unlikely to have been affected by the introduction of the HSCA. We used unassisted births (ie, uncomplicated deliveries which did not require any intervention) as a percentage of all maternal deliveries, since the commissioning of maternity services was largely unchanged by the Act.

We applied a triple-difference approach. The triple difference represents (the change over time in cervical screening rates for CCGs working with only one local authority minus the change over time in cervical screening rates for CCGs working with more than one local authority) minus (the change over time in unassisted birth rates for CCGs working with only one local authority minus the change over time in unassisted birth rates for CCGs working with more than one local authority).

The screening rate is defined as the percentage of women aged between 25 and 64 years who had received a cervical screening test in the preceding 5 years. This indicator was derived from annual, practice-level data from the Quality and Outcomes Framework, 2009–10 to 2015–16. The comparison indicator is unassisted births as a percentage of all maternal deliveries. This indicator was produced using operation codes in Hospital Episode Statistics for 2009–10 to 2015–16. We aggregated the spell-level data by general practice and financial year.

The key assumption underpinning the triple-difference estimator is that, conditional on the other variables in the model, the differences in the changes over time in the intervention indicator (cervical screening) between the ‘exposed’ and the ‘control’ areas (in this case, CCGs working with one local authority vs CCGs working with more than one) would have been the same as the differences in the changes over time in the comparison indicator (unassisted births) between the exposed and control areas in the absence of the intervention. This is a more complex version of the ‘parallel trends’ assumption required for the double-difference, or difference-in-differences, estimator. 17

A popular test of this assumption in the double-difference case is that there are parallel trends over time in the outcomes in the intervention and comparison group in the preintervention period. For our triple-difference case, we used an F-test to assess the joint significance of interactions between the year effects and the binary variable representing the combination of exposed area and treated indicator in the preperiod.

We also used the lagged dependent variable (LDV) estimator. This model is estimated only on data in the postintervention period and is a less biased estimator of treatment effects when the assumption of parallel pretrends does not hold. 18 We set up the LDV model to generate the equivalent impact estimate as the triple-difference model. The model included: dummy variables for year; values of the dependent variable in each of the preintervention periods; a dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority; interactions between year and condition dummies; interactions between values of the dependent variable in the preintervention period and the condition dummy and an interaction between the dummy variable classifying practices depending on whether they were located in CCGs working with more than one local authority and the condition dummy. The final term is the impact estimate, showing whether cervical screening was differentially affected after the introduction of the reforms for local authorities working with multiple CCGs.

We estimated the regression models in Stata V.14.1 using dummy variable weighted least squares regression with fixed effects for practice-indicator combinations. The ways in which these models are estimated using regression analyses are described formally in the technical online  supplementary appendix . As the dependent variable is a proportion, and constrained to lie between 0 and 1, we used the empirical logit transformation and back-transformed the coefficients and associated 95% CIs using the mean value of the cervical screening rate. 19 We clustered the SEs at the GP practice level. 20 The general form of the STATA command is: areg {depvar} {indepvars} [aw=denom], robust absorb(practicexindicator) cluster(practice).

Supplementary file 1

Qualitative findings.

Interviewees told us that CCGs working with more than one local authority experienced a number of challenges, including: finding sufficient capacity to engage in multiple meetings of the same type with different local authorities; managing additional collaborative relationships; working with organisations experiencing different financial pressures from each other with different approaches to public health spending; and attempting to develop integrated health and social care arrangements with one local authority that did not have unintended and undesirable consequences for plans with another. The following extract illustrates issues relating to difficulties commissioning a single service offer for CCG patients and the additional resources required for a CCG working with multiple local authorities. (Interview data extracts are denoted by square brackets with numerical participant ID, participant’s organisation type, Area (1 or 2) and month and year of the interview.)

We do have two sets of safeguarding arrangements. So I guess at one level, one can say there is a risk of and there are examples of services being subtly different. Equally, you’ve got to service two times the number of these processes, which can be quite labour-intensive. [2778, CCG, Area 1, April 2015]

In our analysis relating directly to issues surrounding the commissioning and provision of cervical screening post-HSCA, we identified two main themes: confusion and uncertainty regarding budgets and responsibilities, and potential impacts on cervical screening rates. Many of the issues discussed below are likely to be exacerbated when the number of interacting commissioning organisations in a local area are increased.

Confusion and uncertainty regarding budgets and responsibilities

Before the HSCA, both cervical screening and sexual health services were commissioned by PCTs. As one screening and immunisation lead outlined, cervical screening tests (sometimes referred to as smear tests) were provided by GP practices, but patients could usually also have them at sexual health clinics [17685, NHSE, Area 2, December 2016]. Whereas pre-HSCA PCTs held the budget for both cervical screening and sexual health services, following the Act these budgets were separated. This meant that the local authority budget and responsibility for sexual health did not extend to cervical screening. One local authority public health consultant reported that, in spite of this, PHE was sending letters to patients explicitly stating that they could choose to attend either their GP practice or their local sexual health clinic for their cervical screening test. This highlights confusion regarding commissioning arrangements and budgetary responsibility:

Public Health England were writing around to people saying …you’re due your smear, you can go to your general practice or you can go to your local sexual health clinic. And we said, but we don’t have the money for them to do that, they can’t come here routinely unless you’re going to pay us for that. Public Health England, the screening people, they have the money to pay for the smears. But in all the moving around of the budgets, the money for smears that were taken outside general practice doesn’t seem to be anywhere. [8384, local authority, Area 1, November 2015]

One participant from NHSE offered a different perspective. He argued that the public health budget of each local authority reflected the levels of cervical screening activity that had taken place in its sexual health clinics pre-HSCA. However, this is not clear because, in the past, the funding was not ‘disaggregated’ [4058, NHSE, Area 1, June 2015]. Therefore, it is not possible to establish what the pre-HSCA sexual health component of the public health budget covered.

…they (local authorities) think they’re not being paid for it (cervical screening). But, actually, in truth, whatever they were doing at the point of transition if they were doing loads of cervical smears they were just doing loads of cervical smears, so they had the money. There wasn’t a problem when they were doing them before, it’s just the money wasn’t disaggregated. However local authorities have been put under significant pressure in their public health teams to reduce their budgets. So these kinds of things are examples where you can say it’s not our responsibility so therefore we’re taking that element out. [4058, NHSE, Area 1, June 2015]

The above quote illustrates a phenomenon reported by a number of participants that local authorities had reprocured their sexual health services and had taken a position that they would not commission their sexual health provider(s) to do routine cervical screening, because it was not their commissioning responsibility. However, as one member of a screening team in Area 2 illustrated, NHSE was also reluctant to explicitly commission sexual health services to provide cervical screening, seemingly because of administrative challenges relating to numerous low-value contracts with providers:

So cervical screening, we could go to every sexual health provider and have a separate contract. The difficulty again becomes around commissioning capacity. So, I think we’ve got [x] local authorities, so we have [x] separate contracts all very low value, it’s about 1000 screens in each, so you’re talking maybe [x] £20 000 contracts or something. So, it’s a very bitty way of doing stuff. So, we could still do it and we could pay for it, but in terms of the amount of paperwork or the amount of outcomes it becomes potentially unmanageable. [17685, PHE/NHSE, Area 2, December 2016]

This participant went on to indicate that he would prefer local authorities to commission cervical screening as part of their sexual health contracts, but acknowledged the political difficulties for local authorities to justify spending money on an area of service that was not formally their responsibility, especially given the context of diminishing local authority budgets:

In a way, wouldn’t it be so much easier if the local authorities just included it as part of their normal service? But their argument would be that’s not our role, and how can we defend to the (elected) councillors that we’re spending money on stuff that we don’t have to, that someone else is meant to be spending money on? And our argument is well, it’s just so much simpler and it’s not a lot of money. That’s the kind of discussion. And it eventually ends up with them withdrawing money and us saying well, we’re not buying it either then. [17685, PHE/NHSE, Area 2, December 2016]

Potential impacts on cervical screening rates

One local authority commissioner suggested that the policy of his local authority was to continue to facilitate opportunistic cervical screening tests at sexual health clinics, but not routine tests, because to provide the latter would have a detrimental impact on other sexual health services that the local authority was now obligated to commission (“if we don’t say no to (routine) smears, we’ll be turning (other) people away, symptomatic patients away, or women needing contraception away. And that’s our duty" [8384, local authority, Area 1, November 2015]). He reported that local CCGs complained about this discontinuation of routine cervical screening at sexual health clinics, because there was insufficient capacity within general practice for CCGs to meet their cervical screening targets, and thus they required sexual health clinics to provide a proportion of cervical screening activity. One screening consultant developed this point by suggesting that some localities would see a substantial reduction in screening activity because of a lack of capacity within primary care:

…in some local authorities where the sexual health service is no longer doing cervical screening (it) will have a small impact but not a huge impact, in other areas, it will have a big impact on coverage, we’ll see activity go down around it, because the workload is just going to come straight back to primary care, and in different areas primary care didn’t realise this was happening, the re-commissioning, hasn’t got the capability and the capacity… [18352, PHE/NHSE, Area 1, January 2017]

Another screening consultant reflected that changes to NHSE ‘footprints’ (ie, the abolition of Area Teams and the new, more regional focus of the organisation) had implications for the provision of cervical screening:

…say we wanted to sort out cervical screening coverage in GP practices, in (name of PCT) you’ve got [ x ] GP practices, bottom 20 per cent you could talk to the [ y ] practices. In my new patch we’ve got (many more than x ) practices. So you have to think in a completely different way. [17685, NHSE, Area 2, December 2016]

Several participants from different localities in both geographical areas pointed to long-standing challenges in ensuring good uptake rates for screening among their diverse local populations. There were concerns that these challenges would be exacerbated by a reduction in choice for women about where they could go for cervical screening tests:

…you should have an integrated sexual health service where predominantly women can go in and get seen in one episode, in one place for all their sexual health needs, be that sexually transmitted infection testing and treatment and contraception. So I think probably in the past people worked very hard to get things like cervical screening into these services so that the needs of those women who perhaps wouldn’t go to their local GP could be met in an environment they felt happy with. My feeling is now… that perhaps the type of women who traditionally would have gone for cervical screening (at their sexual health clinic) might not feel so comfortable in that environment (of the GP practice). So particularly, say, a lady from a South Asian background who goes to a single handed male GP with no practice nurse, that’s the kind of traditional person who might have gone to a family planning clinic for their cervical screening. [9742, local authority, Area 2, January 2016]

The HSCA separated commissioning responsibilities for some types of services, including sexual health. Our study participants told us that this had introduced complexity and confusion surrounding cervical screening commissioning, and they expressed concern that screening rates would decline as a result, with some areas potentially affected more than others due to differences in local contextual conditions. In order to explore this further, we designed a quantitative analysis to test the proposition that CCGs most affected by this increase in complexity would have a greater decline in screening rates. Based on the findings from our interviews that working with more than one local authority acted to increase the complexity associated with the commissioning role, we compared screening rates between those CCGs which relate to a single local authority and those required to work with two or more local authorities.

Quantitative findings

There were 14.1 million women eligible for screening in England in 2016. 21 Cervical screening rates decreased over time and the decline predated the implementation of the HSCA in April 2013. Unassisted delivery rates also declined over time. The relative decline between the first year (2009–10) and the last year (2015–16) for unassisted deliveries (−4.17%) was larger than for cervical screening (−2.70%) ( table 3 ).

Numbers of general practices and mean rates of cervical screening and unassisted deliveries by year and by the number of LAs with which CCGs had to coordinate commissioning

The changes in cervical screening rates over time were similar for practices in CCGs dealing with a single local authority (−2.53%) compared with practices in CCGs working with multiple local authorities (−2.87%). Figure 1 illustrates the trends in rates of cervical screening in the preintervention and postintervention periods for CCGs depending on the number of local authorities they worked with. There is a noticeable and sharp decline in the rates in both groups between 2011–12 and 2012–13.

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Uptake (%) of cervical screening pre-HSCA and post-HSCA. HSCA, Health and Social Care Act 2012; LA, local authority.

Comparing the unadjusted averages for the pre-HSCA and post-HSCA years, cervical screening rates decreased by 0.39% more for GP practices located in CCGs working with multiple local authorities compared with practices in CCGs working with a single local authority. Unassisted birth rates decreased by 0.40% less for GP practices in CCGs working with multiple local authorities compared with GP practices in CCGs working with a single local authority. As maternity services were largely unaffected by the HSCA, we assumed that these differential changes captured the unmeasured population influences that confound comparisons of the changes in the two groups of CCGs. Relative to the decreases in unassisted delivery rates, GP practices in CCGs working with multiple local authorities experienced a decrease in cervical screening rates of 0.79% compared with practices in CCGs working with a single local authority ( table 4 ).

Rates of cervical screening and unassisted birth for CCGs working with one and more than one LA, before and after the introduction of the HSCA

The results were qualitatively similar when we estimated the formal triple difference (for all years and 2011–12 onwards only) and lagged dependent variable regression models ( table 5 ). The triple-difference estimates show that there was a differentially larger decline of 0.62% (95% CI −0.941 to −0.297) (model 1) in cervical screening rates for practices located in CCGs working with more than one local authority. The decrease is smaller using the shorter preperiod (0.259%; 95% CI −0.573 to 0.052, model 2).

Triple-difference regression results

The direction of result is robust to the model specification and, although we rejected the assumption of parallel trends for model 1 (all years), we could not reject the assumption for model 2 (2011–12 onwards). We also found a similar result in model 3 using the lagged dependent variable estimator, which yields unbiased estimates when pretrends cannot be assumed to be parallel.

The results are also robust to different groupings of the number of local authorities that CCGs work with. Table 5 includes model estimates comparing CCGs working with one or two local authorities with CCGs working with more than two local authorities. The direction of results is equivalent; and the scale and significance are either equivalent or increased. The same pattern is repeated in terms of tests of parallel trends. We cannot reject the null hypothesis of parallel trends for model 2 and the LDV estimation is preferable to model 1 in which we can reject the null hypothesis of parallel trends.

We conducted a mixed methods study exploring the impact of changes associated with the HSCA in the English NHS on cervical screening rates. We carried out qualitative interviews with senior figures from a variety of relevant organisations in two large, socioeconomically diverse areas of England. Analysis of these interviews suggested that cervical screening commissioning had become more complex, with responsibilities between organisations less certain, as a consequence of the HSCA. Some interviewees predicted there would be a reduction in cervical screening rates in particular areas. These findings prompted the development of an analysis to explore these issues quantitatively via a triple-difference regression analysis of publicly available data on cervical screening activity. To control for unmeasured confounders, we compared cervical screening rates with trends in unassisted birth rates because the commissioning of maternity services was unchanged pre-HSCA and post-HSCA.

Interviewees suggested a number of factors that might contribute to a reduction in cervical screening activity. Sexual health service commissioning responsibility had shifted to local authorities while NHSE was made responsible for commissioning national screening services, including cervical screening. Faced with financial austerity and cuts to their budgets, many local authorities were retendering their sexual health services with sexual health service providers but not including routine cervical screening. NHSE was also seemingly reluctant to commission sexual health clinics to perform cervical screening tests because this would entail a multitude of low-value contracts with numerous providers. This would be administratively laborious and practically difficult given the large size of NHSE’s administrative areas and small numbers of NHSE commissioning staff in each area.

The quantitative analysis was designed to explore whether cervical screening activity had declined in areas most affected by commissioning organisational change. GP practices located in CCGs dealing with multiple local authorities, and therefore most exposed to increased commissioning complexity and potential disruption in services because of the lack of clarity of the roles of different organisations, experienced a larger decrease over time in cervical screening rates compared with practices in CCGs dealing with a single local authority. The opposite pattern was observed for unassisted births, which decreased more over time in the CCGs dealing with a single local authority. The triple-difference analyses confirmed that the effects were statistically significant and robust to different model specifications.

We have demonstrated unintended consequences arising out of a large-scale health system reform. Taken together, our findings suggest that there is an urgent need for clarification as to who holds the budget, and therefore who should be commissioning, cervical screening in the English NHS, and for local agreements to ensure that issues over funding and budgets do not disrupt screening programmes. More broadly, the issues we have identified in this study are of value to policy makers and system leaders in other health systems. The current study suggests that there are particular problems associated with service commissioning where coordination is required between multiple commissioners. This suggests that future commissioning reforms should include assessment of the likely impact on coordination, and a presumption in favour of commissioning all required services for geographical populations where possible. This may also have implications for mixed health systems, in which multiple payers (including public and private insurers as well as out of pocket payments) are responsible for services. In such systems achieving desirable population coverage for services such as screening may require specific coordination efforts.

Potential confounders and study strengths

We took 2009 as our starting point for pre-HSCA cervical screening activity. Two potential confounders to our results were considered. First, the high-profile case of Jade Goody, a reality TV star who was diagnosed with cervical cancer in August 2008 and died in March 2009. The contemporaneous media attention and publicity was linked with a substantial increase in cervical screening rates (around an extra half a million women) during the time between Goody’s diagnosis and death. However, previous impacts of high-profile cases of celebrity cancer diagnoses on population behaviour have tended to be brief and immediate rather than longer-lasting, and, therefore, we are confident that from 2010, rates of cervical screening returned towards underlying trends. 22 Second, the UK’s Human Papillomavirus (HPV) vaccination programme was introduced in 2008 in order to reduce the incidence of cervical cancer. 23 The vaccine is offered to all girls aged 12–13 years, and figures for 2008–14 show high uptake rates of just under 90%. It is likely that this vaccination programme will contribute to a reduction in cervical screening activity in future. However, the first cohort of women in the programme, that is, those aged 12–13 years in 2008, were aged only 21–22 years in 2016–17, hence too young to have been invited for routine cervical screening (which begins at age 25) at the time of the study. We can, therefore, be confident that any changes to cervical screening rates cannot yet be attributed directly to the HPV programme, but any future research into cervical screening rates needs to take this into account.

We considered whether the results were sensitive to the group of CCGs in terms of the number of local authorities they worked with. The direction of results was the same, and the strength and significance was increased, comparing CCGs working with one or two local authorities with those CCGs working with more than two local authorities. We also considered whether the results were sensitive to the choice of comparison indicator (unassisted births) for maternity services. We tested whether the results would hold for another indicator of maternity services: the rate of deliveries by caesarean section. We observed the same direction and significance of results for this indicator as well.

The average age of mothers at delivery is likely to be younger than the average age of women attending for cervical screening. For our analysis, we require that differential changes in maternity indicators between CCGs with simple and CCGs with complex local authority relationships are a good proxy for other factors influencing cervical screening rates. We have confirmed the empirical validity of this assumption by looking for parallel trends in the period before the HSCA, but we can never be entirely sure of its validity.

The findings presented here come from a longitudinal study of major healthcare system reform conducted by a multidisciplinary research team. The nature of this study facilitated the development of the relatively novel, sequential mixed methods approach in which the claims made in qualitative interviews could be tested in a subsequent quantitative analysis. There is a reinforcing effect in this analytical approach, which provides a strong cumulative indication that in areas of the country where complexity and coordination issues linked to the HSCA were more likely to occur there was an associated reduction in cervical screening rates.

Acknowledgments

The authors would like to thank the research participants for their involvement, and acknowledge the valuable advice of the Project Advisory Group.

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Contributors KC designed the study with input from MS, NM, PA, AC. JH, AH, LW-G gathered and analysed the qualitative data. TM and MS designed the quantitative evaluation and conducted this analysis. JH drafted the manuscript to which all authors made substantial contributions. All authors approved the final version and agree to be accountable for all aspects of the analysis.

Funding The report is based on independent research commissioned and funded by the NIHR Policy Research Programme (‘Understanding the new commissioning system in England: contexts, mechanisms and outcomes’, PR-R6-1113-25001).

Disclaimer The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, arm’s-length bodies or other government departments.

Competing interests None declared.

Ethics approval Ethical approval was granted by one of The University of Manchester Research Ethics Committees (application 15085) in March 2015. Participants were provided written information about the study, provided written consent or gave consent verbally at the beginning of telephone interviews.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Patient consent for publication Not required.

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Urban Greening as a Response to Societal Challenges. Toward Biophilic Megacities (Case Studies of Saint Petersburg and Moscow, Russia)

• First Online: 17 March 2023

Cite this chapter

• Diana Dushkova 8 ,
• Maria Ignatieva 9 &
• Irina Melnichuk 10  

Part of the book series: Cities and Nature ((CITIES))

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The population density in megacities is continuously increasing, resulting in a reduction of green spaces and a deterioration in the urban environment quality. Urban green is often being replaced by parking places, shopping centers, and service enterprises. This chapter examines the efforts of two megacities in Russia—Moscow and Saint Petersburg—to organize sustainable greening solutions for their residential areas using new achievements in landscape design theory and practice, such as the concept of the biophilic city. The chapter analyzes the history of greening strategies and discusses the concept of urban green infrastructure and its implementation in both Russian megacities. The chapter presents an assessment of the current state of urban green spaces and the most recent master plans and how these cities are facing and responding to modern societal challenges. The results of an analytical review of the most successful urban greening projects in Moscow and Saint Petersburg are presented as well. The economic and climatic features of the urban green areas and their architectural and planning features are considered, along with strategies for further development of the urban green spaces in both cities, aiming to address the new principles of biophilic cities.

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Acknowledgements

This work was supported by the Russian Foundation for Basic Research (RFBR) project “Mathematical-cartographic assessment of medico-ecological situation in cities of European Russia for their integrated ecological characteristics” (2018–2020) under Grant number No 18-05-406 00236/18 and by the Horizon 2020 Framework Program of the European Union project “Connecting Nature” under Grant Agreement No 730222.

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Diana Dushkova

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Maria Ignatieva

Faculty of Landscape Architecture, Saint Petersburg State Forest Technical University, Institutskij pereulok 5, St.-Petersburg, 194021, Russia

Irina Melnichuk

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Dushkova, D., Ignatieva, M., Melnichuk, I. (2023). Urban Greening as a Response to Societal Challenges. Toward Biophilic Megacities (Case Studies of Saint Petersburg and Moscow, Russia). In: Breuste, J., Artmann, M., Ioja, C., Qureshi, S. (eds) Making Green Cities. Cities and Nature. Springer, Cham. https://doi.org/10.1007/978-3-030-73089-5_25

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Intraurban social risk and mortality patterns during extreme heat events: A case study of Moscow, 2010-2017

Affiliations.

• 1 Russian Presidential Academy of National Economy and Public Administration, 119571, Prospect Vernadskogo, 84, Moscow, Russian Federation; Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 2 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 3 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia; Lomonosov Moscow State University, Research Computing Center, 119234, Leninskiye gory, 1c4, Moscow, Russia; A.M. Obukhov Institute of Atmospheric Physics Russian Academy of Science, 119017, Pyzhyovskiy Pereulok, 3, Moscow, Russia; Moscow Center of Fundamental and Applied Mathematics, GSP-1, Leninskie gory, 1, bld.1, 199991, Moscow, Russia. Electronic address: [email protected].
• 4 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 5 Russian Presidential Academy of National Economy and Public Administration, 119571, Prospect Vernadskogo, 84, Moscow, Russian Federation; Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia. Electronic address: [email protected].
• 6 National Research University Higher School of Economics, International Laboratory for Population and Health, 101000, Myasnitskaya st., 20, Moscow, Russia. Electronic address: [email protected].
• 7 National Research University Higher School of Economics, International Laboratory for Population and Health, 101000, Myasnitskaya st., 20, Moscow, Russia. Electronic address: [email protected].
• 8 Lomonosov Moscow State University, Faculty of Geography, 119991, Leninskiye gory, 1, Moscow, Russia; National Research University Higher School of Economics, Faculty of Geography and Geoinformation Technology, 109028, Pokrovsky bvd, 11, Moscow, Russia. Electronic address: [email protected].
• PMID: 32992266
• DOI: 10.1016/j.healthplace.2020.102429

There is currently an increase in the number of heat waves occurring worldwide. Moscow experienced the effects of an extreme heat wave in 2010, which resulted in more than 10,000 extra deaths and significant economic damage. This study conducted a comprehensive assessment of the social risks existing during the occurrence of heat waves and allowed us to identify the spatial heterogeneity of the city in terms of thermal risk and the consequences for public health. Using a detailed simulation of the meteorological regime based on the COSMO-CLM regional climate model and the physiologically equivalent temperature (PET), a spatial assessment of thermal stress in the summer of 2010 was carried out. Based on statistical data, the components of social risk (vulnerabilities and adaptive capacity of the population) were calculated and mapped. We also performed an analysis of their changes in 2010-2017. A significant differentiation of the territory of Moscow has been revealed in terms of the thermal stress and vulnerability of the population to heat waves. The spatial pattern of thermal stress agrees quite well with the excess deaths observed during the period from July to August 2010. The identified negative trend of increasing vulnerability of the population has grown in most districts of Moscow. The adaptive capacity has been reduced in most of Moscow. The growth of adaptive capacity mainly affects the most prosperous areas of the city.

Keywords: Adaptive capacity; Heat wave; Physiologically equivalent temperature (PET); Urban heat island (UHI); Vulnerability.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Extreme Heat* / adverse effects
• Hot Temperature
• Moscow / epidemiology