Background Part of the rationale for transferring public health responsibilities from the NHS to local government in 2013, was that it would give renewed focus to “upstream” preventive interventions, to improve population health and tackle inequalities more effectively. However there is a risk of potential unintended consequences in terms of the impact on commissioning preventive services at the interface between local government and the NHS. Such services may be difficult to prioritise, particularly given the greater visibility and demand for services for treatment of symptomatic conditions. To date, the actual impact of current commissioning arrangements on preventive service commissioning remains unclear.
The aim of this work was therefore to identify common themes relating to the current barriers and enablers of commissioning prevention services.
Methods Information from interviews and workshops with commissioners and providers were synthesised from two independent projects: a research project exploring barriers to effective management of the Hepatitis B risk in the Chinese community (CATH-B) and a consultation conducted for Public Health England to inform the roll-out of the national Diabetes Prevention Programme (DPP). Data was collected from 23 interviews (3 for DPP; 20 for CATH-B) and 4 workshops (2 for DPP; 2 for CATH-B) for thematic analysis. Findings were discussed with stakeholders to ensure appropriate interpretation and contextualisation.
Results Common barriers that emerged from both commissioner and provider perspectives included: lack of clarity regarding commissioning responsibilities; other competing priorities in the context of finite budgets; lack of understanding of the evidence base; lack of perception that prevention was a priority for services driven by increasing urgent demands; the long-term nature of outcomes for preventive services.
Potential enablers included making the service a higher priority for commissioners by linking it to national targets and funding and the availability of local community providers with capacity to deliver appropriate services. However, the “top-down” nature, and complexities, of commissioning meant using local community-based providers was not always feasible.
Conclusion Since the transfer of responsibility for public health and in a context of shrinking resources, prevention services have been put at risk by lack of clarity about where responsibilities lie, lack of local champions for prevention services in many areas, and complexities of commissioning locally tailored, appropriate and accessible services.
Fragmentation and complexity of commissioning responsibilities and lack of clarity about budgets are widely seen as significant barriers to effective commissioning suggesting integrated budgets “place-based” commissioning will be essential to facilitate effective service commissioning and delivery.
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