Impact of changes to the primary care funding system upon health care networks

Transcription

1 Impact of changes to the primary care funding system upon health care networks R. Sheaff, N. Charles, B. Dowling, J. Schofield, L. Benson, R. Mannion, D. Reeves. Universities of Plymouth, Manchester, Edinburgh and York Plymouth University, 011 Centre Court, 73, Exeter Road Plymouth PL4 0AH, UK 'phone +44-( 0)

2 International context Network structures emerge for governance in the 'hollowed-out state' Public health networks: Unofficial campaigns and coalitions (e.g. 'social movements' against pollution) Official coalitions (e.g swine flu responses) Patient and carer self-help coalitions (e.g. reproductive health) Coordination or management of services across sectors (e.g. community care in Netherlands, UK, USA)

3 English NHS context Increasingly complex networks emerging in primary care Calman-Hine report 'Third-way' politics of networks networks created as policy instrument DH and NHS management interest in 'mandating' networks Quasi-market system and commissioning extended to primary care since 2004

4 Research questions 1. What changes in primary care financing have affected health networks in the English NHS since 2004? 2. What effects have these changes had on networks' activities and organisation? 3. Do the effects differ for NHS and voluntary networks? If so, why? 4. What policy or managerial implications follow?

5 Methods Comparative longitudinal case studies of: Network for young children with mental health problems Self-help network of present and former mental health service patients (adults) Data collection: Longitudinal qualitative narratives Collection of quantitative data on formal network properties (census by questionaire) (Re-use of) managerial data Observation of meetings and public events Analyses: Systematic comparison (framework analysis) of networks Social network analysis

6 Child mental health network: before De facto care network since 1980s - coordinated services for children with mental health problems and their families Formalised core body 2005: budgets from city council and NHS (Primary Care Trust) In 2006, 46 statutory and voluntary organisations = 133 individuals, mainly social workers, nurses, psychologists. From 2008, reconfigured as 'commissioning support network'

7 Self-care network: before Created patients and ex-patients of community mental health services, two relatively deprived suburbs Initial membership 13 individuals + 3 voluntary organisations Formalised core body any member can attend, speak. One voluntary organisation provides a co-ordinator. Mainly use own resources and self-funding. A few small grants Wide range of activities: exercise classes, cooking classes, trips to the sea, Tai Chi, health education

8 Financing English NHS primary care through commissioning 1998 Personal Medical Services contracts Non-GP providers GPs can have locally-negotiated not national contract Contract is with the practice not the doctor 2004 Alternative Provider Medical Services (APMS) 2004 New national GP contract. GP doctors mostly opt out of out-of-hours care (PCT must now arrange it) Another restructuring of PCTs: Merger now the size of former HA Provider activities separated talk of 'social enterprises' Competitive Universities commissioning of Plymouth, Manchester, for Edinburgh all primary & York care services

9 Child mental health network: after Fewer member-organisations now c.13. Commissioners predominate. Provider side members 'let go' not clear what they will do now. Activity shifts from service coordination and projects to managerial outputs: evaluations, care pathways, input to contracts. Becoming more like a sub-committee of city council and PCT. What future?

10 Self care network: after In general, not much qualitative change. Membership grows some events have 60+ participants Regional prize-winner for voluntary health projects PCT and city council staff now attend Seek and obtain NHS pilot project funding ('Let's Get Physical') Start producing bids, evaluations, reports

11 Similarities and differences of network response Increasing documentation of services, specifications, standards, contracts (both networks) Voluntary network therefore experiences increasing: participation by managers and professionals financial dependence on public bodies Otherwise, NHS reforms had little effect on the self-care network Relatively little resource dependence (but see above) NHS communication channels don't penetrate the voluntary network Volunteers not interested in NHS reform or sceptical

12 Policy and managerial implications Voluntary networks can provide 'patient voice' To prevent changes in NHS primary care financing from 'denaturing' voluntary networks requires 'light touch' commissioning or funding by budget / grant. Networks are vulnerable to health system 'redisorganisation' Networked primary care provision is inevitable so policy and management need to accommodate care networks too

13 Questions, comments, good ideas welcome...