What constitutes successful commissioning of transition from children's to adults' services for young people with long-term conditions and what are the challenges? An interview study.

OBJECTIVE: We explored what constitutes successful commissioning for transition and what challenges are associated with this. We aimed: (1) to identify explicit and implicit organisational structures, processes and relationships that drive commissioning around transition; (2) to identify challenges faced by commissioners; and (3) to develop a conceptual model. DESIGN: A qualitative interview study. SETTING: Commissioning and provider organisations across primary and secondary care and third sector in England, UK. PARTICIPANTS: Representatives (n=14) from clinical commissioning groups, health and well-being boards and local authorities that commission national health services (NHS) for transition from children's to adults' services in England; NHS directors, general practitioners and senior clinicians (n=9); and frontline NHS and third sector providers (n=6). RESULTS: Both commissioners and providers thought successful transition is personalised, coordinated and collaborative with a focus on broad life outcomes and actualised through building pathways and universal services. A multitude of challenges were described, including inconsistent national guidance, fragmented resources, incompatible local processes, lack of clear outcomes and professional roles and relationships. No single specific process of commissioning for transition emerged-instead complex, multi-layered, interactive processes were described. CONCLUSIONS: The findings indicate a need to consider more explicitly the impact of national policies and funding streams on commissioning for transition. Commissioners need to require care pathways that enable integrated provision for this population and seek ways to ensure that generalist community providers engage with children with long-term conditions from early on. Future research is needed to identify a core set of specific, meaningful transition outcomes that can be commissioned, measured and monitored.

Senior clinician views regarding introduction of a 'time to specialist' quality measure for unselected emergency admissions.

The reorganisation of hospital emergency care aims to promote rapid access to specialists. In this study, we sought views from senior clinicians regarding the introduction of a 'time to specialist' (TTS) measure to evaluate healthcare delivery. We conducted a thematic analysis of transcripts from semi-structured interviews (n = 13) with clinical leads in a large National Health Service (NHS) Foundation Trust. Three main themes were identified, each with two subcategories: TTS as an appropriate measure (utility and acceptability); recording of TTS information (defining specialist contact and collection of time data); and impact (patient care and service efficiency). Interviewees perceived that a TTS target might improve clinical care for patients with severe illness and service efficiency for milder presentations. There was uncertainty about other patient groups and the definition of 'specialist' in this context. Clinical leads recognised that TTS might be helpful for describing changes in the provision of services, but the impact for patients was unclear because of heterogeneity in presentation and severity of illness for unselected admissions, and challenges in the definition of 'specialist' relative to individual clinical need.

Implementing world class commissioning competencies.

BACKGROUND: The world class commissioning (WCC) programme was introduced in the English NHS in 2007 to develop primary care trust (PCT) commissioning of health services. There has been limited evaluation of health commissioning initiatives over the years and in particular little is known about how commissioners interpret and implement initiatives and guidance intended to strengthen commissioning. This research explores the development and implementation of WCC and draws implications for future commissioning arrangements. METHODS: This research draws on interviews with key informants (n = 6) and a literature review to analyse the aims of, and stimulus for, WCC. In-depth interviews (n = 38) were conducted in three PCTs in the north of England in 2009 to analyse the interpretation and implementation of WCC. RESULTS: The aims and rationale of WCC, in particular, the specification of commissioning skills and the aspirations to improve health outcomes, were largely welcomed and supported by interviewees. However, the implementation of WCC posed a number of challenges, including: availability of resources and knowledge; lack of a supportive organizational culture and networks; and the dominance of central government control. CONCLUSIONS: The findings have implications for emerging clinical commissioning groups (CCGs) in the English NHS. Specifically, the research highlights the need for a system-wide approach to improving commissioning, including appropriately aligned policy and objectives underpinned by a co-ordinated and supportive organizational culture.