‘It is still coming from the centre and coming out’: The material conditions adding to over‐bureaucratised patient and public involvement for commissioning health and care in England

Abstract Objective To understand how materiality affects patient and public involvement (PPI) for commissioning and leading health and care services in the English National Health Service (NHS) context. Context From April 2013 groups of general practitioners (GPs) became members of NHS clinical commissioning groups (CCGs) to assess needs and procure core health services for and with local communities. Since July 2022, integrated care systems (ICSs) have subsumed this responsibility. NHS reorganisations have been driven by the promise of more effective and efficient health care and have led to a long history of PPI on economic, political, and moral grounds. Few studies researching PPI in clinical commissioning exist and fewer still have explored a more agentic understanding of materiality and its impact on PPI. Study Design A focused ethnography was used to examine PPI for clinical commissioning within two CCG case study sites in England. Three CCG Governing Body lay representatives, nine GP commissioners and seven service user representatives took part in focus groups and/or were interviewed. Fifteen nonparticipant observations were also carried out at CCG meetings and the associated materiality was examined. Findings The materiality of activities involved in clinical commissioning influences and shapes the nature of PPI. These forms of materiality may dilute and subvert meaningful engagement and involvement that relies on trust, leadership, learning, and partnership working. Conclusion System leaders in ICSs should consider the significance of materiality in centrally driven processes involved in PPI commissioning to reduce barriers and ensure meaningful partnerships within local communities. Patient and Public Contribution The study design ensured PPI throughout the research process in keeping with contemporary research practice guidance. The project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings.

project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings.  Martin 5 describes as a technocratic rationale for involving patients and the public. Lay expertise is seen as important for assessing value for money, choice and patient satisfaction. In contrast, a democratic rationale for PPI 5 is concerned with living life on more equal terms, providing a voice in public policy and health and welfare services to defend social rights and enhance representation. 6 These different PPI imperatives have led to numerous debates about effective ways to make PPI more sustainable and relevant but even with research and best practice guides, 7-9 the problems of tokenism and superficial engagement remain. 10,11 Most mitigations focus on the procedures refining practices, improving organisation, management and/or levels of education. Whilst some attention to the role of bureaucracy exists more generally, providing useful insights, very few studies have drawn on contemporary understandings of materiality involved in PPI and associated practices. We draw on recent sociomaterial theories where materiality is defined as materials, objects or things that are indivisible from meanings and social and cultural understandings, structuring experiences. These materials are more than mere backdrop, nor are they instrumental, inert or static. This understanding of materiality is entangled with the social, structuring lives, experiences and relations to others, 12,13 and suggests matter is agentic and significantly active. 10 The importance of this account of materiality is evident in notions of participation as advocated by Wenger's 14 'communities of practice' (CoP) theory. Practices comprise materials and meaning which are always ongoing and incomplete. This is evident in, for example, specified criteria, regulations, symbols, documents and contracts as identified in Table 1 16 Therefore, new legislation intends to reduce the bureaucracy, remove competition between purchasers and providers in the NHS and encourage more co-operation and collaboration. [17][18][19] The Health and Care Act 2022 saw 42 Integrated Care Systems (ICSs) in England assume statutory responsibility for strategic planning and resource allocation of health and care services. 17,18 As partnerships between NHS organisations, local government and the voluntary, community and social enterprise sector (VCSE), ICSs are collectively responsible for improving health and reducing health inequalities in their populations. 17,19 Much larger than CCGs, each ICS has an Integrated Care Board (ICB) responsible for planning and funding most NHS services 17 and a number of Integrated Care Partnerships (ICPs) which must produce a strategy for health and care services for communities at local 'place' and 'neighbourhood' level. 20,21 The principle of subsidiarity necessitates partners to listen and learn together as close to the community as possible 21

| SETTING AND METHODS
A focused ethnography was conducted in two case study sites in South-East England. 24 This type of rapid ethnography with shortduration fieldwork is useful for studying healthcare organisation and delivery. 24,25 The principal research question was: 'what does it means to work in partnership as clinicians and service users to commission and lead services'. 26 It encompassed the material conditions and associated bureaucratic processes of commissioning to see if trusted peer relationships were developing for effective PPI.
Focused ethnography aims to describe and explain cultural aspects within a group or sub-group and so uses first-level questions-the 'what?' questions. 27 Secondary questions probe further and explain; 'what helps or constrains?' 27

| Study design
To obtain contextual background data 28 three focus groups were initially used, followed by 15 nonparticipant observations at CCG meetings where PPI should have been taking place. Thirteen interviews were subsequently conducted, and relevant documentary sources were analysed. These included minutes of meetings and field notes together with CCG website content. 29 Material artefacts are important sources of evidence used to confirm or contrast observational and interview data. 27 Focused ethnographic techniques typically utilise multiple visual, auditory, and photographic artefacts, however, the method was modified to preserve confidentiality and maintain anonymity.
A research project steering committee including three service users and one PPI practitioner, all with commissioning experience in the preceding 5 years, helped assess the rigour of the data collection and interpret the findings, as well as ensure the project remained focused on its intended aims.

| Settings and participants
The two case study sites comprised an urban CCG and a rural CCG.
Entry to the study sites and access to participants was via the two Engagement Officers responsible for PPI work in their respective CCGs. Participants were therefore a convenience sample. The 11 focus group participants were either exclusively service users and lay representatives or exclusively clinicians (GPs) with a leadership role in the CCG ( There was also one service user representative (paid expenses only) involved with service procurement. Three interviewees also took part in the initial focus groups because only two lay representatives were appointed to comply with NHS England CCG requirements. 30 T A B L E 1 The social and material aspects of participation.  Both urban CCG focus groups (Table 2) were held on CCG premises. The rural CCG service user focus group was held in the home of one of the service users for participant convenience. The prompt questions (Table 4) were the same for all focus groups.

| Data collection
Observations were completed in the two CCG case study sites

| Data analysis
The qualitative data analysis software package NVivo version 11 was used to manage and make sense of the large amount of text data.
Summaries of 'data bundles' are sometimes employed in observations and field notes that need to be condensed. 31 Figure 1 summarises the data flow and management. Codes and some data bundles were checked by members of the project steering committee and co-authors KA and BF. The remaining eight categories of codes informed four data bundles of PPI practices for clinical commissioning, designated as trust, leadership, learning and partnership, (Table 5). Two categories, 'roles' and 'Governing Body' (italicised in Table 5) appear in more than one data bundle.
Analysis was both deductive and inductive. The data bundles were conceived deductively as four sets of situated learning practices (Table 5). A theory-informed framework was then applied, the components ( Table 6) of which were drawn from a range of sociomaterial theories such as social learning theory and practice theories, based on the dynamics of social practice, 32 professional learning 33 and 'communities/landscapes of practice'. 14,34,35 Both CCGs referred to CoPs as a form of engagement and preferred way of working aligned to good practice. The nature of these is reported elsewhere. 26 This framework fully attends to the materiality of practices and themes were derived inductively from each set or data bundle, allowing us in this paper to re-explore and argue for the importance of materials in PPI in commissioning.

| Ethics
The study received university ethical approval and underwent proportionate review by the National Research Ethics Service.
Letters of Access were also obtained for both CCG settings.

| FINDINGS
We focus on the heavy materiality within CCG engagement and involvement practices that bureaucratise PPI processes, revealing how materiality impacts and can hinder trust, leadership, learning, and partnership working practices. The narrative draws on themes derived inductively from the framework in Table 6. Pseudonyms are used throughout consistent with Tables 2 and 3. GB agendas followed a set structure which addressed common features of the meetings including the declaration of interests, minutes of the last meeting and matters arising, governance, quality and performance, delivery and strategy, reports, and minutes from subcommittees. Most of the content was for noting rather than discussion.

| Voluminous governance artefacts
The emphasis was on procedure to process and report the work of the CCG rather than decision-making. The many activities of the CCGs were captured within GB documents using a standardised template for consistency and transparency. Reporting 'patient and public engagement' on the template, the CCGs used impersonal phrases such as: Patient representatives were engaged throughout the procurement exercise and formed part of the evaluation team. They have been consulted on the service model.
[Reporting outcome of procurement for a community service, urban CCG]

| Overdominance of centralised agendas
Having to adhere to centralised agendas was often seen as unhelpful and symptomatic of an over  [Lay representative for PPI, urban CCG focus group]   49 To some degree these aspects were evident in the study data although the new breed of nonclinical commissioners was a welcome departure.

| Recognition of leadership track record
A limitation of the study is that the work of the commissioning support managers was not captured more fully within the focused ethnography. One GP lead referred to her 'awe-inspiring' commissioner, but comments came from all study participants. The commissioners, new to post in both CCGs, were influencing the service users and lay representatives as well as the clinicians. They brokered and led some of the negotiations in the various work streams or communities of practice. They were a new type of commissioner with a different approach and skill set for learning together and in partnership. Reliable and speaking on the same level without effect or superiority were two features of their practice that instilled trust.

| CONCLUSION
Although findings from qualitative research cannot be generalised, this sociological-focused ethnography allowed a pragmatic approach to exploring PPI social practices for clinical commissioning. In this paper we have explored the materiality affecting and frequently hindering commissioning processes due to excess bureaucracy relative to trust, leadership, learning, and partnership working. Conceptualisation (supporting); writing-review and editing (equal).