Linda Marks

Objectives: Shifting the focus of health-care systems towards prevention has proved difficult to achieve. Governance structures are complex, incentives may conflict and there are many competing priorities. We explored the influence of governance and incentive arrangements on commissioning for health and well-being in the English National Health Service (NHS) and the governance paradoxes which emerge. Methods: Qualitative and quantitative methods were employed. We carried out one national and two regional focus groups; a national online survey of primary care trusts (PCTs); and 99 semi-structured interviews in 10 purposively selected case study sites across England. Interviewees included decision-makers in PCTs, practice-based commissioners, Chairs of Local Involvement Networks (LINks) and of Overview and Scrutiny committees (OSCs) and Voluntary and Community Sector (VCS) members of local health and wellbeing partnerships. Results: Case study sites differed in the extent to which they reflected a public health ethos throughout the commissioning cycle, incentivized preventive services through contractual flexibilities or prioritized investment in health and wellbeing. Practice-based commissioners were tangentially involved in the commissioning cycle, public health partnerships or local health needs assessment. While commissioning for health and wellbeing involves working through partnerships, performance management regimes favoured single organizational success. Preventive services were considered at increased risk in times of financial stringency. Conclusions: As the NHS in England undergoes further reorganization, it is important to ensure that a systematic, strategic and population-based approach to commissioning is not lost. Governance and incentive arrangements should be critically assessed for their impact on population health and wellbeing.

General practitioners in the UK play a key role in prevention but provision of preventive services is variable. The 2004 General Medical Services contract allows Primary Care Trusts (PCTs) to address health needs through providing locally agreed payments for Local Enhanced Services (LESs). This study identifies how this contractual flexibility is used for preventive services and explores its perceived effectiveness. Semi-structured interviews were carried out (2008–09) in 10 purposively selected case study sites in England. Details of LESs for these sites were collected (2009) through Freedom of Information requests or local contacts. A national on-line survey of PCTs (2009) provided a national context for case study findings. LESs were considered to be effective in incentivizing preventive activity. However, specifications and performance management were often weak, awareness of how to optimize incentives was low and, as optional services, LESs were perceived to be at risk in a financial downturn. Using LESs for preventive services highlights gaps in ‘core’ primary care responsibilities and in the national pay-for-performance framework. Current incentive arrangements are complex, could increase inequalities and provide only a partial, short-term solution to developing a proactive approach to prevention in primary care.

Purpose – The purpose of this study is to explore gaps between policy and practice in relation to the involvement of voluntary and community sector (VCS) members in local strategic partnerships (LSPs), using the example of inequalities in health. Design/methodology/approach – Documentary analysis; semi-structured interviews with VCS representatives from a sample of LSPs in one region of England; semi-structured interviews with key researchers and national stakeholders. Findings – National policy imperatives to expand the role of the VCS in decision-making and to make LSPs an important avenue for addressing inequalities in health are not always translated into practice. VCS members are at the sharp end of tensions in LSPs between thematic and neighbourhood approaches, local views and strategic priorities and between democratic and participatory approaches to decision-making. Effective engagement in addressing inequalities in health requires a strategic approach across the LSP which is reflected in the priorities of each of the constituent partnerships. Research limitations/implications – This is a snapshot of LSPs at one point in time and local interviews are restricted to one region of England. Practical implications – The article illustrates good practice and barriers to VCS involvement in addressing inequalities in health through LSPs. This is relevant to a range of public health partnerships. Originality/value – The views of VCS members on addressing inequalities in health through LSPs have not previously been researched, despite their key role. Lessons are relevant for multi-agency strategic partnerships with a public health focus in England and internationally.

Evidence of effectiveness is prominent as a basis for decision-making. Addressing inequalities is a key UK policy objective to be implemented through national and local strategies. Tensions that emerge in adopting an evidence-based approach for tackling inequalities in health are only partly due to limitations of the evidence base in this area. Three research and development projects on different aspects of addressing the inequalities agenda, carried out in the North East of England between 2000 and 2002, explored how local decision-makers tackled inequalities in health and how this issue was reflected in local strategies. These projects illustrate the breadth of this agenda, different ways in which it can be conceptualized and prioritized at a local level and barriers to its implementation. It is argued that evidence of effective interventions plays a relatively small part in decision-making at a local level. In order to address inequalities in health, greater attention should be directed to ways in which the inequalities agenda is embedded within local monitoring and decision-making processes.