Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK.
School of Health Sciences, University of Manchester, Manchester, UK.
BMJ Open. 2019 Apr 14;9(4):e024156. doi: 10.1136/bmjopen-2018-024156.
Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms.
Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes.
Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups.
Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.
探讨 2012 年《健康和社会关怀法案》（HSCA）在英格兰引入的委托改革对经实证确定在组织上受改革影响特别大的地区的宫颈筛查活动的影响。
定性与定量方法相结合。定性：对 NHS 委托方、管理人员、临床医生、来自临床委托组（CCG）的高级行政人员、地方当局、服务提供者进行半结构化访谈、观察英格兰两个大都市的委托会议。定量：对全国行政数据进行三重差分分析。通过比较与一个地方当局合作的 CCG 与与多个地方当局合作的 CCG，衡量 HSCA 对委托的预期影响的变异性。为了控制未测量的混杂因素，比较不太可能受到 HSCA 委托组织变革影响的 CCG 与另一个结果（受 HSCA 变化影响不大的非辅助分娩率）之间 25-64 岁女性的宫颈筛查率随时间的差异变化。
受访者认为，在 HSCA 之后，宫颈筛查委托和提供更加复杂和“碎片化”，责任更加不确定。受访者预测，这将导致一些地区的宫颈筛查率下降幅度大于其他地区。定量结果支持了这些预测。与处理一个地方当局的 CCG 相比，处理多个地方当局的 CCG 经历了更大的宫颈筛查率下降（1.4%）。在此期间，两组的非辅助分娩分别下降了 1.6%和 2.0%。
HSCA 扰乱并使宫颈筛查的委托和提供变得更加复杂。受影响最大的地区的筛查率下降幅度大于其他地区。这一发现先是通过定性识别，然后通过定量证实，这一事实增强了这一发现。该研究表明，大规模的卫生系统改革可能会产生意想不到的后果，复杂的委托安排可能存在问题。
