The distressing reality that mental healthcare for children and young people in acute trust settings in the UK is woefully underprovided is not news. But with acute trust debts being written off, hospital trusts and commissioners of services have a timely opportunity to address this age- and condition-based discrimination.

Delivering a just service for under-18s depends on attitude, resources and adequate knowledge of the tasks involved. This article aims to describe the current landscape, summarise the arguments for better integrating mental healthcare into physical healthcare settings, articulate the tasks involved and the challenges for commissioning and providing, and finally share examples of current service models across the country.

Ultimately, commissioning and provider choices will be constrained by resource pressures, but this article aims to underscore why commissioning and providing a portmanteau ‘no wrong door’ hospital service for children, young people and families is worth the headache of thinking outside old commissioning and provider boxes.

The policy drive to support carers is a longstanding national and international priority. Research about the design and delivery of support for carers is critical to the underpinning evidence base. Through a timely exploration of a third sector perspective, the UK-based study discussed in this article provides insights into approaches to, and the commissioning of, support for older carers and carers of people with dementia. The study highlights the importance of: embedding carers’ perspectives in service developments; the provision of both generic and targeted support which adopts a nuanced and tailored approach; titrating the delivery of information and advice at a pace to match carers’ needs; capturing quantitative and qualitative dimensions in service evaluation; and increased quantity and longevity of funding. Such insights not only complement existing research but are also generalisable to other countries at a similar stage in the development of carer support.

In the context of a mixed economy of welfare, public policy in the UK and elsewhere has long promoted third sector involvement in delivering public services. A growing research literature consistently highlights the challenges third sector organisations face engaging with a demanding public services commissioning environment, but it tends to lack a theoretical basis and can offer misleading accounts of third sector organisations as relatively passive and powerless in the face of wider forces. This article argues that third sector organisations actively operate within and seek to shape a commissioning context which advantages some strategies and some types of organisation over others. To provide stronger theoretical foundations for understanding public services commissioning and the third sector, the concept of ‘strategic selectivity’ (Hay, 2002) is applied to in-depth qualitative longitudinal data from third sector organisations delivering a range of public services. The article contributes new theoretical insights into the dynamic ways in which social policies and public services are organised. The analysis highlights how differently positioned organisations seek to read, navigate pathways through, and transform an uneven public services commissioning landscape.

To our knowledge no previous studies have been conducted at the local authority level assessing relationships between alcohol-related hospital admission, specialist alcohol treatment provision and socioeconomic deprivation since the UK government passed the Health and Social Care Act in 2012. Our results, using publicly available national data-sets, suggest that the local authority areas in England most in need of adequately funded specialist alcohol treatment, because of high prevalence of alcohol dependence and deprivation, are not receiving targeted increased funding, and that the national rise in alcohol-related hospital admissions may be fuelled by local authority funding cuts to specialist alcohol treatment.

Home care for older people in England is commissioned through local authorities working predominantly with independent providers of care. Commissioners operate in a market model, planning and procuring home care services for local populations. Their role involves ‘managing’ and ‘shaping’ the market to ensure an adequate supply of care providers. Another imperative, emerging from the principles of personalisation, is the drive to achieve user outcomes rather than ‘time and task’ objectives. Little formal research has investigated the way commissioners reconcile these different requirements and organise commissioning. This study investigated commissioning approaches using qualitative telephone interviews with ten commissioners from different local authorities in England. The characteristics of commissioning were analysed thematically. Findings indicated (a) commissioning involved complex systems and processes, uniquely shaped for the local context, but frequently changed, suggesting a constant need for reframing commissioning arrangements; (b) partnerships with providers were mainly transactional, with occasional examples of collaborative models, that were considered to facilitate flexible services more appropriate for commissioning for personalised outcomes; and (c) only a small number of commissioners had attempted to reconcile the competing and incompatible goals of tightly prescribed contracting and working collaboratively with providers. A better understanding of flexible contracting arrangements and the hallmarks of a trusting collaboration is required to move beyond the procedural elements of contracting and commissioning.

Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring ‘practice languages’ is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor ‘care pathway’ is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as ‘designing a pathway’ may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.

This paper reports on the commissioning tests performed on a new GE Lightspeed RT wide-bore computed tomography (CT) scanner with GE Advantage Sim software. This paper focuses on the laser marking system, CT hardware and the interfaces between each component of the system, and generalises the findings to most CT simulation systems currently available. A discussion on the commissioning of the virtual simulator software will follow in a separate paper. Three phantoms were used (two constructed in-house) to assist with a range of tests covering aspects such as the laser patient marking system, CT hardware, and connections between the CT scanner, virtual simulator system and the treatment planning system (TPS) and VARiS. Tests performed showed the CT simulation system to be working within acceptable tolerances suggested in the literature, and baseline data have been obtained against which future comparisons of system performance have been made. Where no tolerances were available, we have suggested suitable values. While considering tolerances on Hounsfield number variation that may lead to a dose error in excess of 2%, we found that in the case of low-kV CT scanning the range of Hounsfield numbers for dense bone was outside the acceptable limits for potential dose errors and so users were advised not to perform radiotherapy planning CT scans with kV below 100 kV.

This paper continues the discussion on the commissioning tests performed on a new GE Lightspeed RT wide-bore computed tomography (CT) scanner, focusing on the GE Advantage Sim software (version 6.0).

The tests performed and phantoms used to assess the virtual simulator functionality, including the 3D image display, contouring, treatment unit beam parameters, digitally reconstructed radiograph generation and image quality, isocentre generation and multi-modality image registration, are described.

The series of tests performed showed the virtual simulation software to be working within acceptance tolerances suggested in the literature and baseline data have been obtained against which future comparisons of system performance have been made. Where no tolerances were available, we have suggested suitable values.

The current government has given priority to two different objectives in reorganizing the National Health Service (NHS) in England and Wales. The first objective is to create a primary care-led NHS by organizing commissioning of hospital and community health services by new primary care organizations. The second objective is to improve quality and performance in the NHS and to assess this using evidence in various ways. Previous research has suggested that the changes GPs wish to make to services are often not based on published evidence. This suggests a conflict between the two principal objectives intended to drive the reorganization of the NHS. The aim of this study was therefore to explore these issues further. An interviewer-administered questionnaire survey was conducted on one general practitioner and one public health physician from each of four total purchasing pilots (TPPs) in Wales and their four host health authorities, respectively. The main outcome measures were the types of evidence used, and the extent to which evidence impacted on decisions. Access to evidence and views about its usefulness are also reported. It was found that more high-quality evidence was used in support of disease-specific than in support of non-disease-specific changes to care. Evidence played a greater role in decisions to change services that were purchased by health authorities, or provided by TPPs, than it did in changes to services purchased by TPPs. Similarly, higher quality of evidence was used when making decisions to change services that were purchased by health authorities or provided by TPPs, than for services that were purchased by TPPs. It is concluded that there is a mismatch between the availability of conventional, disease-specific evidence directed at the delivery of care, and the need for other kinds of evidence for commissioning changes in the organization of care. This means that we need research and development to develop new methods and new types of evidence so that we can assess the benefits of commissioning in a primary care-led NHS.

Primary care trusts (PCTs) will play a major role in commissioning and evaluating new services in primary care. Several studies have discussed the problems associated with conducting evaluative research in primary care generally. However, few GP commissioned services have been formally evaluated, so little is known about the feasibility of such research in the PCT setting. This study uses a tool called force field analysis to identify factors that drive and restrain a primary care-based randomized controlled trial (RCT) of a newly commissioned service for patients with psychosocial problems in primary care, and also to suggest strategies for building on positive factors and reducing negative ones. It involves discussion with general practitioners (GPs) and other primary health care team (PHCT) members in practices with access to the service. Several important dynamics emerge from the analysis with regard to the likely success of evaluation of a new service. These are availability of research skills and funding, prior beliefs about the service and participation in primary care, existing evidence of effectiveness and financial accountability, research design and awareness and ownership in primary care. This study provides evidence that force field analysis can serve as a helpful tool for anticipating and identifying barriers to, and partnerships and actions needed for, successful evaluative research in primary care. It can also facilitate the development of practical strategies to aid successful service evaluation. We suggest that the strategies identified by this study could usefully inform plans for future evaluations in the setting of the PCT.

Aim: To describe a general practice commissioning project including 19 nonfundholding practices in Buckinghamshire: its structure, aims, representativeness, outcomes, costs and sustainability, and lessons learned from the process over the first 18 months.

Method: Examination of project documentation; postal questionnaire to all 73 participating GPs and to eight key players in the Health Authority (response rate 72%); and in-depth interviews with six Health Authority staff and 15 general practitioners (GPs).

Results: A representative structure and process were established for GP involvement in commissioning. 75% of GPs were involved. Mutual understanding improved between the GPs and the Health Authority. Service improvements identified included developments in orthopaedics, community psychiatric nursing, physiotherapy and ophthalmology. Lessons were learned about the importance of open and continued communication; clarity about expectations, accountability, power and responsibility; development of relationships and understanding in joint working; the time required to achieve tangible results; and the need to develop GPs' commissioning skills.

The project cost about £10000 in cash and £32500 in staff time in the first year. Participants perceived their input as sustainable.

Conclusion: The results of the study suggest that the success of Primary Care Groups will depend on ensuring engagement of all parties in the process, clarifying roles, responsibilities and expectations, identifying shared agendas, developing explicit and achievable goals, and a commitment among all parties to implement recommendations. The work and time involved in developing mutual respect and shared understanding, and in developing commissioning skills need to be acknowledged.

One of the key objectives of the community care reforms of 1990 in the United Kingdom was the development of a flourishing independent sector alongside good quality public services. The aims of the reforms were to increase the available range of options, widen consumer choice and promote independence. The purpose of the study reported here was to examine – from the perspective of older service users, their carers and care managers – experiences at the operational level of arranging, delivering and receiving care services. The findings are based on data gathered in seven local authorities including reviews of case files, policy documents and face-to-face, in-depth interviews with 55 users, 37 carers and 28 care managers. There is evidence of a pronounced emphasis on procedure-based systems of care management. Potentially this has two significant consequences. First, the fostering of personal relationships may be subordinated to the organisation of short-term tasks and thereby may threaten patterns of trust and accountability. Second, the associated fragmentation of the assessment and care management process which in turn can lead to discontinuities of care for users and their carers. The paper concludes that there is still some way to go before care managers as micro-commissioners have sufficient and reliable information or available service capacity to match providers' capabilities with users' and carers' needs.