Decision-making in English Clinical Commissioning Groups: A Mixed Methods Study

Abstract

This research primarily investigated the Clinical Commissioning Groups (CCGs) in the English NHS to identify factors influencing effective decision-making as perceived by General Practitioners (GPs) with formal roles in CCGs. A study by the British Medical Association (BMA) (2014a) revealed that GPs at practice level felt that CCGs were developing policies that restrict efficient delivery of health care. As such, I developed a hypothesised conceptual model demonstrating factors at play in the decision-making process, which I tested using Partial Least Squares Structural Equation Modelling (PLSSEM). Alongside, informed by the conceptual model, was the qualitative strand, with the data that I analysed under interpretative phenomenological analysis (IPA). Quantitative and qualitative data were collected simultaneously through a survey using a questionnaire in a convergent parallel mixed methods design, underpinned by a philosophical position of pragmatism. Data was collected in 2017. Research sample consists of 73 GPs in the UK. The hypothesis testing results show that GP Proportion has a significant and positive effect on Decision-making Process Effectiveness. Similarly, the effect of GP Influence has been found to be significant and positive on Satisfaction. In contrast, the effect of GP Influence on Decision-making Process Effectiveness has been found to be insignificant. This result is also observed regarding the effect of GP Influence on Member Practice Wishes Met. Five key themes were identified from the qualitative data analysis – namely, (1) Financial, focused on decisions influenced by financial concerns, (2) Bureaucracy, centred on decisions influenced by the bureaucratic hierarchy, (3) Clinical, to do with decisions that were perceived as having clinical implications, (4) Workplace culture, focused on behavioural patterns affecting decision-making within the organisation, and (5) CCG role, based on the way the role of CCGs was understood by member practices and the way that engagement of member practices was achieved by the respective CCGs. The results contribute to theory and practice. Regarding practice, notwithstanding the intended autonomy for the CCGs, which was aimed at improving patient care by aligning health care commissioning decisions with local needs, structure alone appears not enough to deliver effectiveness, as perceived by GPs. The proportion of GPs was found to be a relevant factor, while leadership and local CCG level culture, coupled with communication and governance, are also important. Finance was found to be significant, with many concerns about CCG policies attributed to this factor. On contribution to theory, the general observation is that the CCGs appear to be moving from professional to bureaucratic organisational model (Mintzberg 1979), thereby threatening the purported autonomy. This study also revealed new information on the formal roles that GPs occupy in CCGs, as previous research showed limited awareness in this regard (Checkland et al. 2016). Information gathered on committee memberships and the positions GPs occupy highlights the complexity and diversity of GP roles in CCGs.