Checkland Katherine, McDermott Imelda, Coleman Anna, Perkins Neil
Centre for Primary Care, University of Manchester, Manchester, UK.
BMJ Open. 2016 Jan 7;6(1):e010199. doi: 10.1136/bmjopen-2015-010199.
The reform in the English National Health Services (NHS) under the Health and Social Care Act 2012 is unlike previous NHS reorganisations. The establishment of clinical commissioning groups (CCGs) was intended to be 'bottom up' with no central blueprint. This paper sets out to offer evidence about how this process has played out in practice and examines the implications of the complexity and variation which emerged.
Detailed case studies in CCGs across England, using interviews, observation and documentary analysis. Using realist framework, we unpacked the complexity of CCG structures.
SETTING/PARTICIPANTS: In phase 1 of the study (January 2011 to September 2012), we conducted 96 interviews, 439 h of observation in a wide variety of meetings, 2 online surveys and 38 follow-up telephone interviews. In phase 2 (April 2013 to March 2015), we conducted 42 interviews with general practitioners (GPs) and managers and observation of 48 different types of meetings.
Our study has highlighted the complexity inherent in CCGs, arising out of the relatively permissive environment in which they developed. Not only are they very different from one another in size, but also in structure, functions between different bodies and the roles played by GPs.
The complexity and lack of uniformity of CCGs is important as it makes it difficult for those who must engage with CCGs to know who to approach at what level. This is of increasing importance as CCGs are moving towards greater integration across health and social care. Our study also suggests that there is little consensus as to what being a 'membership' organisation means and how it should operate. The lack of uniformity in CCG structure and lack of clarity over the meaning of 'membership' raises questions over accountability, which becomes of greater importance as CCG is taking over responsibility for primary care co-commissioning.
2012年《健康与社会照护法案》下的英国国家医疗服务体系（NHS）改革不同于以往的NHS重组。临床委托小组（CCG）的设立旨在自下而上，没有中央蓝图。本文旨在提供关于这一过程在实践中如何展开的证据，并探讨所出现的复杂性和多样性的影响。
对英格兰各地的CCG进行详细案例研究，采用访谈、观察和文献分析。运用现实主义框架，我们剖析了CCG结构的复杂性。
背景/参与者：在研究的第一阶段（2011年1月至2012年9月），我们进行了96次访谈，在各种会议上进行了439小时的观察，开展了2次在线调查和38次后续电话访谈。在第二阶段（2013年4月至2015年3月），我们对全科医生（GP）和管理人员进行了42次访谈，并观察了48种不同类型的会议。
我们的研究突出了CCG中固有的复杂性，这源于它们发展所处的相对宽松的环境。它们不仅在规模上彼此差异很大，而且在结构、不同机构之间的职能以及全科医生所扮演的角色方面也存在差异。
CCG的复杂性和缺乏统一性很重要，因为这使得那些必须与CCG打交道的人很难知道在什么层面与谁接触。随着CCG朝着实现医疗与社会照护的更大整合迈进，这一点变得越来越重要。我们的研究还表明，对于作为一个“会员制”组织意味着什么以及应该如何运作，几乎没有共识。CCG结构缺乏统一性以及“会员制”含义不明确，引发了关于问责制的问题，随着CCG接管初级医疗共同委托的责任，这一问题变得更加重要。
