Factors in implementation of clinical commissioning policy in improving health and wellbeing and/or reducing health inequalities in the English NHS: a systematic review of the evidence


 Objective: This study aimed to identify and synthesise the factors in implementing clinical commissioning policy in improving health and/or reducing health inequalities in the English NHS. Methods: Systematic review was conducted. We searched Medline, EMBASE, CINAHL, Allied & Complementary Medicine, DH-DATA, Global Health and CINAHL for primary studies that assessed the enablers and barriers, and reported in accordance with PRISMA statement. Methodological quality was appraised using JBI Critical Appraisal tools and Mixed Methods Appraisal Tool [MMAT] to assess the methodological qualities, and synthesised performing thematic analysis. Two reviewers independently screened the papers and extracted data. Results: We included six primary studies (including a total of 1155 participants) in the final review. The studies reported two broad categories, under four separate themes: agenda of health inequalities not fully addressed; poor evidence for reducing health inequalities; reform through restructuring of organisations, and strategic approaches. Conclusion: This study provides useful factors – enablers and barriers – to implement and deliver clinical commissioning policy in improving health and wellbeing. These factors could be assessed in future to develop objective measures and interventions to establish the link between commissioning and health inequalities improving equitable access, health outcomes and effective partnerships.


Introduction
Since the establishment of the English National Health Service (NHS) in 1948, several organisational changes have been made, equally in uenced by the components of commissioning and health inequalities. 1 Commissioning is an approach to moving services from hospital to community settings, to avoid potential cases of emergency admissions as admissions trends have risen, 2-4 as well as reduced health inequalities that may impact positively on the social determinants of health. 5(p.5) In the NHS, commissioning is more about health planning or strategic purchasing. 6 1. Articles published in narrative review, opinion pieces, letters and any other publications lacking primary data including grey literatures.
2. Studies deemed to have overall poor quality.

Search strategy
A broad search strategy has been designed to maximise the level of sensitivity and speci city in searching, 32 and improve both recall ratio and precision ratio. 33 Medical subject heading (MeSH) and free terms to focus and broaden our search results appropriately for commissioning and health inequalities were used in the main search combined with the UK lter developed by Ayiku et al. 34 A detailed SR protocol with speci c search terms has been developed by authors, and provided in Additional le 1.

Study selection strategy
All studies emerging from the databases have been screened twice: rst, screening of abstracts and titles against minimum inclusion criteria. Second, review of full text of the studies. The standard PRISMA ow diagram was used to provide the process of study selection 35 (Fig. 1).

Quality appraisal of included studies
Methodological quality was appraised using JBI Critical Appraisal tools 36,37 and Mixed Methods Appraisal Tool [MMAT] 38 to assess the methodological qualities. These tools have established content validity and have been piloted across all methodologies. [39][40][41] The retrieved papers were assessed by two reviewers (KR and OM) using the standardized 10-item, 9-item and 5-item critical appraisal checklists for qualitative assessment, quantitative and mixed methods studies, respectively. To facilitate comparison of appraisal processes, both reviewers recorded the rationale for inclusion or exclusion, and discrepancies were discussed and resolved by consensus. Table 1 presents the results from the critical appraisal.

Data analysis and synthesis
Studies in this review were not su ciently homogenous to analyse using meta-analysis. 42 Therefore, results are summarised using qualitative narrative synthesis and tabular form. 43,44 As Joff 45 suggests, we examined these themes and sub-themes on "their similarities, differences and contradictions", to be able to address the research question about potential barriers (challenges) and facilitators (bene ts) of clinical commissioning on reducing health inequalities. Coding process and the development of themes throughout the analysis were discussed among authors.

Results
The search results are summarised in Figure 1. We identi ed 2166 references, scanned 133 titles and abstracts and retrieved 42 publications for full texts. From these, we included six studies (including a total of 1155 participants) that reported data on clinical commissioning and health inequalities 46-51 and excluded 36 studies (Additional le 2). Of the six, four were qualitative. [46][47][48][49] All studies were conducted between 2010 and 2017 and the list of included studies is presented in Table 2.

Synthesis of evidence
This study is organised under four major themes/ ndings which emerged.
Finding 1: An overwhelming majority (5 of 6 papers, 83%) of the papers indicated the agenda of health inequalities has not given priority by clinical commissioning The primary and overriding nding of this study is that clinical commissioning (CC) has not given health inequalities as a priority agenda of the commissioning process. Some evidence indicated that CC was more considered a public health activity to determine health needs of individuals or populations by identifying, assessing and prioritising their needs and actions as general public health functions rather than commitment to reducing health inequalities. 46 One paper, however, reported that CC has been used as a tool to improve service improvements to address inequalities. 47 Participants expressed these aspects thus: Commissioning was considered as one of the broad aspects of public health activity […] identifying needs, reviewing service provision, deciding priorities, procuring services, and managing performance. 51 Responsibility for the health inequalities agenda was seen primarily as a function of public health roles rather than part and parcel of core healthcare commissioning work, even where PCTs had adopted explicit strategic priorities relating to inequalities. 47 CCGs understand primary care and local needs. Allowing CCGs to commission primary care alongside other services would support the development and implementation of local strategies for service improvement, support innovation in primary care and allow investment in primary care (by allowing resource shifting). 46 Finding 2: More than half (4 of 6, 67%) of the papers reported reform through restructuring and organisations, and strategic approaches in collaboration, commitments and engagement as bene ts of commissioning in healthcare.
The bene ts of clinical commissioning have been reported across different studies. Based on further analysis of the papers, three major bene ts emerged: a) Context and restructure of services: Since the Health and Social Care Act (HSCA2012), the commissioning process has been much better in terms of understanding the wider social-political context of local healthcare, recognising wider consultation on decision-making to plan and deliver health services involving local elected people and organisations. Similarly, this reform has relocated public health from NHS to local government, and prepared staff for transition to deliver integrated approaches. 51(p.4) The following extracts illustrate issues relating to service context and restructure: The relocation of public health from the NHS to local government provided important context for the introduction of IHWSs. Participants in both sites felt there were new opportunities to work across local authority directorates to address the wider determinants of health and health inequalities. 48 There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong in uence 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 nancial constraint. 51 b) Strategic approaches -service integration and commitment: CC offers greater knowledge and understanding of integrating local health services re ecting data to local health plans. McDermott et al. 46 (p.7) further add that "Integrated care [in the context of CC] requires detailed local work to build trust and develop context-speci c mechanisms to work across boundaries." Similarly, a great commitment through investment has been given within council services to improve public health to meet needs and expectations. Included papers reported these aspects as follows: Potential for greater integration of knowledge and data on local communities, stronger JSNAs and better understanding of needs, was noted with the move of public health to Local Authorities. In addition, new structures, particularly the HWBB, created the possibility of new opportunities for representation. 47 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 in uence the wider workforce. 51 Both local authorities had a long-term strategic commitment to community development and asset-based approaches, which was seen as bene cial by public health commissioners. 48 c) Partnership and engagement: The association between CC and wider healthcare partnership and engagement has been reported positively in terms of meeting healthcare needs by reducing duplication costs/resources and sharing knowledge and expertise. These studies conveyed this view: Expressed concerns that CCGs would have to start a lot of community engagement work from scratch, and develop meaningful relationships with key communities. Engagement was seen by many participants to be important not just for understanding population needs, but also in commissioning services that effectively meet those needs. 47 …recognised and articulated the potential added value of collaborative working between NHS and local authority partners, plus the third sector in WFL. Anticipated bene ts included reducing duplication, extending the reach of existing services and programmes, sharing expertise and capacity and maximising opportunities for innovation. The idea of offering a more streamlined accessible approach, which seeks to knit together a number of different functions was broadly welcomed. 48 GPC endorsement of the social model of health underpinning LWG and WFL, there was also broad acceptance of prevention and early intervention, recognised as being more cost-effective than long-term treatment. 48 Finding 3: All six papers (100%) indicated that there was some poor evidence for reducing health inequalities through the clinical commissioning process, primarily due to poor approaches utilised in decision-making, lack of budgets, time, strategic priorities, and poor commitments.
These barriers have been broadly categorised into two levels: a) Structural impediments: all papers reported that in commissioning, the decision-making process was a challenge as it demanded wider consultation with a range of policy-planners, politicians, and decisionmakers at local levels. Similarly, studies reported commissioning responsibilities have been fragmented between different organisations (NHS England, PHE, local councils and CCGs), and co-ordination was slow, di cult and bureaucratic. 48,51 Therefore, there was serious concern raised not only about diluting local authorities' action on health inequalities but also failing to recognise and reduce health inequalities because of poor direction from central government and poor commissioner engagement in health services commissioning. 47,49 The extracts below illustrate this: Decision-making within councils was found to be very different to that within PCTs. 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 di cult. 51 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 to streamline their organisations and reduce sta ng costs. The positioning of public health teams within councils varied. 51 Poor track record of shifting resources out of secondary care and into the types of primary care and public health interventions felt to be capable of achieving a signi cant impact on health inequalities. 47 b) Personal impediments. More than half of the papers reported personal impediments (3 of 6, 60%) to reducing health inequalities in the CC process. Commissioners' inadequate level of knowledge and expertise, poor trust/relationships between local authorities and staff involved in the commissioning process, poor partnership, working in different geographical locations and engagement, and a largely pessimistic approach have been reported as major challenges. 47 Some extracts below illustrate this: Most commissioners did not view identifying and tackling ethnic inequalities in healthcare access, experience or outcomes as part-and-parcel of their job due to lack of clarity about their responsibilities. 51 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. 51 Similarly,Pressures to get both services 'off the ground' quickly, coupled with different organisational cultures, a history of competing for contracts and mistrust arising from short-term contracts and reducing budgets, may have destabilised early efforts to build relationships among staff and with communities. 48 Finding 4: Most papers (4 of 6 papers, 67%) indicated improving health services, appropriate policy and approaches should be in practice These studies reported service improvement associated with availability, affordability, and accommodation or exibility of services. 50 Similarly, organisational contexts, appropriate translating of evidence into practice, were factors reported that in uence health services locally improving. The extracts below highlight some relevant issues: Staff, costs, and opening hours were the commonest areas where participants made recommendations for improvements to local dental services. 50 Greater accountability of healthcare commissioners to the public and more in uential needs assessments via emergent Health & Wellbeing Boards. 47 Investment and opportunities contained in national and local initiatives were seen as major contributors to enabling CCGs achieving a people-centred, locally driven,integrated primary care service with general practice. 46 Fig. 2 is a conceptual framework (CF) that emerged from this study, noting that making the commissioning is a continuous assessment process. To make the effective link between CC and reducing health inequalities, this will give a stronger link between public health and broader work on the social determinants of health; putting people at the centre of the framework ensures their needs are appropriately met by providing best-quality care in primary care services. The approach would also give more immediate results in improving public health, making it part of the local political landscape. 52 It is therefore important to routinely monitor the inequalities in access and health outcomes. This CF also acknowledges the skills and capacities of GPs and other healthcare providers in leadership and governance, and ensures they can ful l their operational and strategic roles. 53,54 Discussion This study was undertaken to synthesise the evidence in relation to CC and health inequalities, as there is a rich heritage of addressing health inequalities within the NHS. The study reported clear gaps due to different commissioning structures, different roles, nancial pressures, accountabilities, responsibilities, GP skills and competencies, organisation experience and local contextual conditions, to address inequalities in policy and practice. 46,55 Our study identi ed different facilitators and barriers (Table 3), clearly aligned with the Marmot health inequalities review, stating that health inequalities are determined by a complex mixture of factors. Access to healthcare was one of the pillars, and other were the wider determinants of health, e.g. income, housing, education, employment, lifestyles. 11 Marmot 11 also argued that "addressing health inequalities at earlier stages of life was the surest way to reduce the long-term incidence of health inequalities". NHS also reported that "reducing health inequalities improves life expectancy and reduces disability across the social gradient. Tackling health inequalities is therefore core to improve access to services, health outcomes, improving the quality of services and the experiences of people." 14(p.11) Table 3 Enablers and barriers to clinical commissioning and the contribution of each study eme McDermott et al. 46 Turner et al. 47 Cheetham et al. 48 Salway et al. 49 Al-Haboubi et al. 50 Gadsby et al. 51  Due to implementation of CC, this study has revealed holistic, targeted and integrated approaches which are clearly bene cial to reduce health/social inequalities. It is because the remit of commissioning involves assessment of local needs as well as deciding priorities and strategies and purchasing services for local populations -strategic purchasing. 46,56 CC has been viewed as a new and integrated model of care holding promise for addressing inequalities largely at the provider:patient interface. 57, 58 We also argued that through CC, it is not just about having enough GPs, but also whether they listen to the whole community. 58 Our study also found that power and decisions have been shared with communities and service providers, but still there are some gaps or challenges in terms of transformation of funds and availability of funds to run community services and their priorities are structured differently. 59 Therefore, changing culture of communities from passive consumers to active partners would be one of many options to make wider access to healthcare possible. 58  considered "central to all models of primary care-led commissioning", involving both the components of service improvement and service redesign. 46,62 In fact, such interpretations are supported by earlier work, 13,14 i.e. effective GP engagement to take on a greater level of responsibility in the commissioning of primary care services would be an important role, as reported by our own study. This study has further highlighted that one of the challenges GPs faced was due to poorly de ning their roles in clinical commissioning, as well as the size of population they should cover. 64 Similarly, frustration at work among GPs, mainly due to increased volume of work and lack of resources, have been reported as major barriers since the implementation of HSCAct12 which has also been reported in Humphery and Claver's ndings. 65 Working in collaboration with a wide range of stakeholders would help develop appropriate local healthcare strategies and evidence-inform policy in practice. 60,66 Unequal distribution of funds between the primary and secondary care resulting in ine ciencies and poor performance have also been reported as other barriers. As reported in the previous study, 67 we also found some limited attention to ethnic diversity and inequality within healthcare commissioning. From the users' perspective, our study has reported that users' demand and expectations in line with the demographic changes would certainly in uence GPs' ability in terms of (re)designing and (re)shaping primary healthcare services at the local level, as highlighted in other similar studies. 65,68-71 Therefore, as Checkland et al. 64 suggested, it is important to support the development of new models of service provision and work more closely with LAs, other providers (e.g. voluntary sector) and other local bodies (e.g. health and wellbeing boards) for commissioning of primary care services.

Strengths and limitations of the review
To our knowledge, this review might be the rst systematic review to examine the factors -enablers and barriers -since the implementation of CC for improving health quality and reducing health inequalities in the English NHS. This review was conducted using a comprehensive search strategy developing a systematic review research protocol. DH 72,73 and NHS Improvement 74 proposed some commissioning cycles, but how a commissioning model would be meaningful in addressing health inequalities has not been reported before. This study has proposed a CF embedding input-process-outcome (IPO) con guration, putting users at the centre of the process in terms of bringing positive outcomes in improving quality care, mitigating possible barriers and enhancing enablers or facilities (Fig. 2), and also highlighting enablers and barriers to clinical commissioning and each study contribution (Table 3).
This review has, however, a number of limitations. First, the potential limitation of this study is that as this study was not externally funded, and therefore time and resource were constrained, we were unable to include and review grey literatures. Second, studies are variable in sample size, quality and population, which are open to bias, and also due to the heterogeneity of data, it precludes a meaningful metaanalysis to measure the impact of speci c enablers or barriers, therefore the ndings warrant generalisation. Third, despite overall good methodological quality of the included papers, some studies provided inadequate descriptions of study methods and procedures. 46,47,51 Fourth, as Maden 75 reported while considering health inequalities in systematic review, "there was no validated search lter for health inequalities", therefore it was di cult to search the databases using the exact terms. However, we used the this term based on those used in a Cochrane methodological review exploring how effects of health inequalities are assessed in SRs, 76

Conclusion
The current systematic review highlighted that effective CCGs are essential to promote equality, improve health outcomes and reduce health inequalities. This study provides useful factors -enablers and barriers -to implement and deliver CC policy in improving health and wellbeing. These factors could be assessed in future monitoring/evaluation of local primary care services. Further research is needed to nd the best methods and approaches in terms of developing objective measures and interventions to establish the link between clinical commissioning and health inequalities effectively, e ciently and equitably.