Health policy, the politics of governance and change: The introduction of Clinical Commissioning Groups in context

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Abstract

The Health and Social Care Act 2012 (HSCA12) represents one of the more dramatic reforms in the history of the English National Health Service (NHS) in terms of scope and pace. The flagship of the policy was the replacement of Primary Care Trusts with Clinical Commissioning Groups (CCGs): General Practitioner (GP) led “membership organisations” with responsibility for planning and purchasing most NHS care. A new “arm’s length” body, NHS England (NHSE), was created to authorise and oversee CCGs. The purpose of this research was to critically explore the ideational content of the HSCA12 and consider it in relation to social practices at the organisational level of a CCG: to provide a detailed, contextualised account of a CCG’s early operation, paying particular attention to the implications of its officially intended status as a membership organisation. By problematising the HSCA12, I have highlighted how CCGs and the GPs that constituted them were presented as an emancipatory force saving the NHS from ineffectual managers that lacked clinical and local knowledge about what patients needed; membership organisation status was bound up with this claim of local representation, and the policy attempted to orchestrate engagement from GPs as members through normative devices and governance systems including legislation and assessment programmes. However, the policy elided the difference between GPs as individuals and GP practices and left ambiguous precisely who or what constituted a member.Thirteen months of fieldwork using ethnographic methods (meeting observations, interviews, documentary analysis) were carried out with a case CCG: Notchcroft. The policy delineated “the membership” and “the governing body” as sub-groups within the CCG, but I found many others were involved in CCG governance processes and created “the governing core” concept to describe them. Confusion in the policy over exactly who was a member was paralleled in the CCG. The governing core, many of whom were GPs, were involved in performance assessment processes of GPs in order to fulfil a legal obligation to NHSE. This represented a further redrawing of the GP/state relationship and was a source of identity dissonance. The governing core also actively transmitted national policy norms about what it meant to be a member to the broader membership. By trying to “sell” CCG membership and encourage engagement they were attempting to legitimate the organisation and their roles within it. Notchcroft CCG’s unusual structure, with two levels (districts and locales) below central committees, appeared inefficient. This structure developed as a response to previous national commissioning policies. The institutional logics approach—employed as an analytical lens—proved useful in explaining its endurance: districts were containers for identity and interests to be protected, whilst locales were established and maintained as local “self help” organisations to support quality improvement. The initial purposes of districts and locales thus represented different logics of action that appeared self-evident to those involved, although they were less obvious to an external observer. In time, these initial logics were eroded, and districts and locales were given additional functions. These findings illustrate the emergent tension between national policy and local enactment, and demonstrate how local socio- historical context plays an important role in shaping how policy is realised in practice.

Keyword(s)

ethnography; governance; health; institutional logics; nhs; observation; policy

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