Patient and public involvement in priority‐setting decisions in England's Transforming NHS: An interview study with Clinical Commissioning Groups in South London sustainability transformation partnerships

Abstract Background Patient and public involvement (PPI) in health‐care commissioning decisions has always been a contentious issue. However, the current moves towards Sustainability and Transformation Partnerships (STPs) in England's NHS are viewed as posing the risk of reducing the impact of current structures for PPI. Objective To understand how different members in clinical commissioning groups (CCGs) understand PPI as currently functioning in their decision‐making practices, and the implications of the STPs for it. Design Thematic analysis of 18 semi‐structured interviews with CCG governing body voting members (e.g. clinicians and lay members), non‐voting governing body members (e.g. Healthwatch representatives) and CCG staff with roles focussed on PPI, recruited from CCGs in South London STPs. Results There are contestations amongst CCG members regarding not only what PPI is, but also the role that it currently plays and could play in commissioning decision making in the context of STPs. Three main themes were identified: PPI is ‘going out’ into the community; PPI as a disruptive power; and PPI as co‐production, a ‘utopian dream’? Conclusions Long‐standing issues distinctive to PPI in NHS prioritization decisions are resurfacing with the moves towards STPs, particularly in relation to contradictions between the rhetoric of ‘partnership’ and reorganizations that foster more top‐down control. The interviews reveal pervasive distrusts across a number of levels that are counterproductive to the collaborations upon which STPs rely. And it is argued that such distrust and contestations will continue until a formalized space for PPI in STP priority‐setting is created.


| BACKG ROU N D
England's National Health Service (NHS) is currently in a state of transformation centred on integrating the commissioning and provision of health and social care services, through place-based partnerships. This process, started in 2016, has been set in motion without legislative backing, framed instead as locally driven changes to working relationships and cultures, aimed at fostering collaboration, trust and devolved budgetary power, with the aim of enhancing efficiency, responsiveness to local population needs and ending 'fractured' care. 1,2 Clinical commissioning groups (CCGs) (themselves only established in 2012) are GP-led statutory bodies, whose role involves 'assessing local needs, deciding priorities and strategies, and then buying services on behalf of the local population from providers such as hospitals, clinics, community health bodies etc…'. 3 They have been a key site at which this drive towards integration has been initiated. Through a variety of arrangements, CCGs are now working collaboratively as Sustainability and Transformation Partnerships (STPs), in some cases with a view to evolving into integrated care systems (ICS), in which priorities and management of resources are agreed upon at a systems level, which, for instance in London, equates to the equivalent of 4-6 CCGs in each of the five London STPs. 4 From the outset however, STPs have been criticized for not sufficiently involving NHS staff, patients, publics and local government, and their non-statutory nature has only heightened public distrust of the process and fears of creeping privatization. 5,6 Patient and public involvement (PPI) in the NHS has always been considered an important aspiration but remains a contentious issue, often lacking a clear rationale in regard to aims and means, along with evidence of outcomes. 7 Nevertheless, whilst it has managed to maintain its position in successive NHS reorganizations, as Hudson argues, the current STP process in which commissioning decisions are functioning on larger scales (e.g. shared contracting, the formal merging of CCGs) poses the risk of sweeping current structures for PPI into irrelevance. 6 In this interview study, carried out between October 2017 and May 2018, we look specifically at PPI in NHS priority-setting decisions, seeking to understand how different CCG board members and staff covered by two South London STPs understand and observe PPI as functioning in practice, and the implications they perceive there being for PPI in STP commissioning. In so doing, we strive to elucidate practice-based insights into the role[s] and associated challenges of PPI in commissioning decision making, and how different people and groups doing PPI are navigating the emerging STP process.
Activist campaigning for public representation in NHS spending and planning decisions dates back to the 1960s. 8 The first formalized structures were the Community Health Councils (CHCs), which were created in 1974; however, PPI in priority-setting decisions was only first legally articulated in the 2001 Health and Social Care Act (HSCA-Section 11). This policy section has survived subsequent policy amendments, and in its current form requires CCGs and NHS England (NHSE) to 'make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways): a) in the planning… b) development and consideration of [change] propos-als… and c) decisions' 9 (p.50-51 -italics added). NHSE use terms such as 'involvement', 'engagement', 'consultation' and 'participation' interchangeably 9 ; however, Stewart identifies them as 'synonyms of uncertain equivalence' and tabulates the different scholarly typologies of PPI, all of which categorize terms according to the 'level' or degree of power gained by citizens. 10 Notably, the terms used in policy-consulting and informing (italicized above)-are in what she describes as the 'uncontroversial middle range' 10 and signify citizen power that is a 'level' below the STP-defining term 'partnership'. Nevertheless, references to the co-design of personalized health budgets (PHBs) for patients with chronic conditions in London STP plans do indicate partnership in commissioning, although the implementation of this being described as patient representatives sitting on CCG boards and committees 11 does raise questions of whether the myriad of processual challenges to doing meaningful co-design is appreciated. 12 Earlier research is certainly indicative of there being wide disparities between the rhetoric and reality of PPI in commissioning self-management. 13 The King's Fund identifies STPs and ICS' as creating opportunities for advancements in PPI, for 'joined-up listening' in which patient insights can be integrated across entire pathways of care. 14 However, a historical lens indicates two main on-going tensions that underlie PPI in priority-setting in England's NHS and which need attention. The first relates to the ambiguous conceptualizations of PPI, owing to how state-driven forms of public management that frame PPI in democratic terms as 'voice' have been conflated with market-driven framings of PPI as 'choice'. 15,16 In the public forums that replaced CHCs, this could be seen in how despite using the language of 'partnership' (indicating voice), 17 'the public' were used more as a 'sounding board', akin to market research, that legitimized pre-defined policies and priorities, as opposed to having any real influence of their own. 18 And today, the framing of patients with PHBs as 'integrators' of STPs 19 also indicates this rhetoric of choice as empowerment, that Tritter identifies as dangerous in that health systems are needs-rather than wants-based. 16 Nevertheless, the legitimacy of democratic framings of citizen power in the NHS has from the outset also been called into question owing to issues of representativeness. 15,[20][21][22] The second tension relates to the shifting functions of PPI (both 'invited' and 'uninvited') 10 : PPI has been identified as holding the power Way' philosophy obscured the 'publicness' of public services and recast the public sphere as a 'series of horizontal spaces' in which citizenship and participation were localized, for instance on a specific service, rather than something that was held in common, displacing possibilities for wider justice and equality claims. 29 And since then, research indicates that publics are struggling to mobilize, weakened by their not sharing a collective identity. 30

| ME THODS
This paper draws on data that were collected as part of a larger qualitative study that sought to understand how a wide range of social values influence decision making in CCGs (of which [patient and public] participation was one). 36 These values had been derived through a series of workshops which included local PPI representatives. 37 Twelve CCGs, making up two STPs, in the South London area were approached through networks arising from the research team's place in the South London CLAHRC, and emails were sent out inviting members of the CCGs to participate. 'Members' in this study context are understood to include voting governing board members (e.g. clinicians, lay members), non-voting governing board members (e.g. Healthwatch representatives) and CCG staff. As indicated in Committee, and all participants in the study gave informed written consent.
The interviews were semi-structured and questions asked participants to first articulate how they understood a particular social value (e.g. accountability, transparency, participation, clinical effectiveness, cost-effectiveness, fairness, quality of care), and then discuss their views on its influence in CCG decision making, giving examples when possible. No specific questions were asked about the STPs, yet they were discussed in all but three interviews. This paper only reports on the collected data pertaining to participation.
The transcripts were analysed thematically using both a deductive and inductive approach, 38 in which codes were inductively identified in relation to each of the social values deductively focussed on, but also for any values that were inductively identified. All interviews were double-coded by KK and CC to ensure robust analysis, and themes were collaboratively identified through multiple discussions between KK, CC and PL. For the purposes of this paper, themes were searched for in all the coded sections of text that pertained to PPI, and developed by also maintaining a view of the different perspectives of the members' positioned roles and experiences.

| RE SULTS
The interview analyses revealed contestations in understandings of not only what PPI is, but also the role that it currently plays and could play in commissioning decision making in the context of STPs. In some cases, these differences in understanding were related to the roles of interviewees, arguably indicative of the on-going power tensions between managers, clinicians and publics. However, there were also interesting disagreements amongst the various non-clinicians, and in commissioning as co-production, a 'utopian dream'? Each will now be discussed in turn.

| PPI as a disruptive power
The disruptive powers of patients and publics were identified by many interviewees, albeit from quite different perspectives. The cli-

| PPI in Commissioning as Co-Production, a 'Utopian Dream'?
A number of the non-clinicians identified how PPI in commissioning should mean 'co-production', however in the same breath, questioned whether this could ever be a reality. Part of this doubt was related to the quick time frames that all interviewees referred to as limiting PPI and that many described as having gotten worse with Two of the non-clinicians raised a concern about CCG decision-making processes in general, in that a lot of the influencing or ideas behind decisions 'happen in private in the discussions between the CCG managers and their GP representatives' (HW7  contradiction in the NHS: its centralized control borne out of considerations of equity, but which has more recently been co-opted by regulatory agencies; and its devolution, encouraging the responsivity and accountability of local decision-makers to their publics, yet which has also given rise to critiques of 'postcode lotteries'. 43,44 Rather, we suggest that they are being felt more acutely now because the 'rules of the game' are changing: meaningful democratic, 'invited', participation relies on socioeconomic securities that enable at least a consensus on procedure. 45 And in the current contexts of austerity measures, 'post-truth' distrust of elites, and a health system that is clearly governed through a manager-led market model whilst using the rhetoric of partnerships (once more), 46 such securities are glaringly absent.

| D ISCUSS I ON AND CON CLUS I ON
A comparative analysis of the UK's four health systems highlights how the creation of trusting relationships and collaborative work is hardest in fragmented and unstable systems, such as England's NHS. 47 Furthermore, a recent experiment aimed at creating a 'space' for co-productive learning between researchers, clinicians, patients, carers, and managers also illustrated how even at a 'distance' from NHS spaces, the institutionalized scripts that structure power asymmetries are enormously difficult to disrupt. 48 Nevertheless, both studies emphasize the essentiality of public support and the legitimization of 'non-professional' knowledge for NHS transformations and collaborations, respectively, that in the current contestatory context requires specific attention. 47,48 It is therefore concerning that in the NHSE guidance for delivering the STPs, PPI is referenced in isolation from discussions on the need to apply 'social movement principles' in health and care, indicating that patients and publics are not perceived to be a part of this 'collective agency'. 39 Yet, the 'collective' and 'movement' aspects of the suggested transformation strategies are also themselves questionable. In that 'framing the issues in ways that engage and mobilise the imagination… [and] continually refreshing the story' (p.15-16) 39 reflects more of a top-down public relations and marketing logic, that not only sustains power asymmetries, but is at odds with the solidarity, emancipatory goals and [self-initiated] collectivizing enactments through which mobilization for pre-figurative change takes place. [49][50][51] Therefore in highlighting differences in how PPI in commissioning is understood in the context of STPs, this study reveals that whilst the creation of more formalized spaces for PPI at higher levels of STPs are needed, so too is practice-based evidence on the relational dynamics that can initiate and sustain collaborations between different identity groups in England's NHS. Not only do STP leaders have to act as boundary spanners, bridging built-in conflicts of interest between commissioners and providers, health and social care organizations, and different patients and publics who are becoming increasingly more contestatory, they must also somehow inspire trust in a system that at present lacks any form of socioeconomic security. This is a task that requires much more than 'compelling narratives' and inspirational leadership, 39 and reasserts the residual power of patients and publics in England's NHS.