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Commissioning in health, education and social care: models, research bibliography and in-depth review of joint commissioning between health and social care agencies |
Newman M, Bangpan M, Kalra N, Mays N, Kwan I, Roberts T |
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CRD summary This review assessed the impact of the joint commissioning of services between agencies in two different sectors, for example, health and social care. The authors concluded that evidence on the impact of joint commissioning was from a comparatively small number of methodologically weak studies, and could not be regarded as compelling. These conclusions reflect the limitations of the evidence presented. Authors' objectives To assess the impact of the joint commissioning of services, between agencies in two different sectors, for example, health and social care. Searching Fourteen databases, including MEDLINE, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials (CENTRAL), were searched to February 2010. Searches of websites of relevant organisations and research centres, peer-reviewed journals, and the Internet, using Google and Google Scholar, were carried out. Reference lists were checked and experts were contacted to identify further studies. It was unclear whether language restrictions were imposed, but only studies in English were included in the review. Study selection Study selection was conducted in two stages: a broad scoping literature review, then an in-depth review of the impact of joint commissioning between health and social care agencies. The in-depth review sought to identify factors affecting the impact of joint commissioning. For inclusion in the in-depth review, studies had to be about joint commissioning (as defined in the report) across sectors or with inter-sector collaboration. Studies had to investigate or explore specified aspects or types of joint commissioning. It appears that studies could be of any design, except audit or monitoring reports or country-level case studies. Studies had to report the relevant outcomes of commissioning. All, except one, of the studies included in the in-depth review, were conducted in the UK. All of them investigated joint commissioning at an area or local level, between health and social care agencies. Some studies also included education. In most studies, multiple services were jointly commissioned, but in some cases the focus was on a specific service or a specific section of the population. It appears that study selection was performed by single reviewers. The principal investigator screened a sample of records, a second time, for quality assurance. Assessment of study quality Study quality was assessed using the EPPI Centre's Weight of Evidence framework. This assessed quality of execution, whether the study had an appropriate design, and whether the study provided sufficient information on, or had a particular focus on joint commissioning, or both. An overall measure of trustworthiness, for each study, was derived from these three assessments. The authors did not report how many reviewers assessed quality. Data extraction Data were extracted by one reviewer using a pre-developed and piloted coding tool. This coding was checked by a second reviewer. Differences were resolved by discussion or by involving a third reviewer. Methods of synthesis A narrative synthesis was conducted. The impacts of joint commissioning were categorised as service-user outcomes; costs; technical efficiency; organisational management outcomes; or partnership-related outcomes. The barriers and facilitators to joint commissioning were coded and a thematic analysis was carried out. The thematic analysis was guided by a framework which explicitly identified key components of partnership working. Results of the review Six hundred studies on the impact of commissioning were identified. Of these, 25 investigated the impact of joint commissioning, and these were included in the systematic review. The UK studies were classified as low quality because they provided information about respondents' views on the impacts of joint commissioning rather than any comparative outcome data. Thirteen studies reported the impact on service-user outcomes. A medium quality study from Sweden found no difference in outcomes between co-financed and non-co-financed rehabilitation centres. All other studies were low quality. Four UK studies argued that joint commissioning improved services, and therefore improved outcomes for service users and staff. Four studies reported perceived benefits of joint commissioning on quality of life, for service users. Four studies reported that joint commissioning was associated with changes which were of concern to service users, such as the introduction of charges; reduced access; lack of choice; longer waiting times for equipment; and isolation. Other impacts were discussed in the report, which suggested some conflicting evidence on partnership working; perceptions of efficiency; and staff morale and commitment. The factors affecting impact were divided into four linked categories: inputs, such as leadership; context, such as geographical boundaries; internal, such as agency structure; and relationships between partners, such as trust and understanding. Evidence was considered to be of moderate quality (details were given in the report). Cost information Six low-quality studies from the UK reported on costs. Two reported savings from lower administration and transaction costs. Two reported cost savings from economies of scale. One study argued that pooling of budgets increased financial flexibility, but another study reported problems with dual accounting systems, potentially increasing transaction costs. Authors' conclusions The evidence on the impact of joint commissioning was from a comparatively small number of methodologically weak studies, and could not be regarded as compelling. CRD commentary The review addressed a very broad question, only part of which was related to the effects of an intervention (joint commissioning). The inclusion criteria were correspondingly broad and covered both quantitative and qualitative studies. The search was thorough and included sources of unpublished and grey literature. Study quality was assessed, using criteria which were appropriate for the range of designs included. The review processes were not all conducted in duplicate, but it seems unlikely that this would have affected the review findings. A narrative synthesis was appropriate. The largely descriptive vote-counting synthesis reflected the limitations of the evidence. As the authors noted, almost all the studies of impact were of low quality. Given the lack of clarity about potential confounding, the reliance on respondent views, and the absence of comparative outcome data, the authors stated that confidence in the causal relationship between commissioning arrangements and outcomes was limited. The authors' cautious conclusions seem appropriate. Implications of the review for practice and research Practice: The authors did not state any implications for practice. Research: The authors stated that rigorous comparative research was needed to evaluate the impact of different types of commissioning. Funding Funding received from the UK NIHR. Bibliographic details Newman M, Bangpan M, Kalra N, Mays N, Kwan I, Roberts T. Commissioning in health, education and social care: models, research bibliography and in-depth review of joint commissioning between health and social care agencies. London: University of London, Institute of Education, Social Science Research Unit, EPPI-Centre. EPPI Report; 2007. 2012 Indexing Status Subject indexing assigned by CRD MeSH Delivery of Health Care; Health Care Reform; Health Services Needs and Demand; Humans; Social Work; State Medicine AccessionNumber 12013015544 Date bibliographic record published 20/03/2013 Date abstract record published 25/04/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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