London School of Hygiene & Tropical Medicine

In April 2013, the National Health Service (NHS) in England was subject to the biggest reorganisation since its creation in 1948.  NHS leaders famously described the changes as “so big you could see them from space”.

In a very short space of time, new organisations were created, old ones abolished and responsibilities for public health were transferred from the NHS to local authorities. In the midst of these changes, we investigated what happened to the national immunisation programme.

Health care reforms and devolution have been shown to unsettle and disrupt public health programmes; recent examples include Pakistan, Indonesia and Kenya. Such major governance changes seem to affect vaccination programmes disproportionately, because by nature and history they have often been nationally driven. The consequences for a critical public health “vertical” programme such as vaccination are organisational upheavals, ambiguity in leadership and uncertainties over funding responsibilities.

However, very few studies have examined how health care reforms affect public health programmes, hence the work we recently published in the BMC Health Services Journal provides unique insights. Our study involved interviews with national immunisation leaders and people involved in delivery of the immunisation programme in three different regions of England.

We found that the April 2013 health reforms resulted in significant fragmentation in the way the immunisation programme was delivered, and gaps in the support and performance management of providers. However, it is fair to say that the consequences for the programme were mitigated by previous high performance and the strength and dedication of staff who have striven to hold the programme together over the past few years.

We found in our study that changes in governance arrangements resulted in a lack of clarity over the roles and responsibilities of each organisation, and how the various entities involved – NHS England, Local Authorities Public Health Departments, Clinical Commissioning Groups (CCGs), and Public Health England – could best work together to deliver a strongly performing programme. We heard that significant effort had to be expended on making the new system work and pulling things back together. In addition, immunisation managers are now responsible for larger areas and as a result are less able to interact with general practice and community based staff.

This meant that both at national and local levels the success of immunisation hinged on developing strong partnerships and collaboration arrangements between different organisations involved in the programme. In a context where all organisations are financially stretched, this type of collaboration was reported to be very time consuming. To date, different areas are still trying to develop effective partnership structures and processes.

Without advocating for more structural changes, there is a case for improved utilisation of different partner organisations’ strengths. For instance, local authority Public Health Teams and CCGs that are responsible for smaller geographic areas than sub-national Screening and Immunisation Teams (SITs) could do more to strengthen outreach to under-vaccinated communities and review the performance of their constituent practices, respectively.

Our findings provide lessons for many countries which see devolution of health services as a remedy for poor performance and a lack of local accountability. Reorganisation of health systems needs to take into account the specificities of public health programmes, which transcend local boundaries and cover the whole population. A well performing immunisation programme needs to ensure herd immunity and must promote a whole population approach.

There is an argument that public health programmes benefit from national leadership which supports delivering equity and aims to serve underserved populations which may struggle to access health services. In any case, it is critical when re-designing health systems to understand how public health services will be affected by large-scale reforms including devolution – and to mitigate for unintended consequences.

Publication: Tracey Chantler, Saumu Lwembe , Vanessa Saliba , Thara Raj , Nicholas Mays , Mary Ramsay and Sandra Mounier-Jack. It’s a complex mesh”- how large-scale health system reorganisation affected the delivery of the immunisation programme in England: a qualitative study. BMC Health Services Journal. DOI 10.1186/s12913-016-1711-0

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