News Release

Commissioning in the English NHS should be abandoned

Peer-Reviewed Publication

BMJ

Commissioning in the English NHS is a failing system that needs to be abandoned, says a public policy expert in an editorial published on bmj.com today.

Professor Calum Paton from Keele University argues that since 1991, purchasing or commissioning "has mutated through a series of confusing and frequent reorganisations, involving mutually incompatible policies and high costs."

He believes this system should be dropped in favour of a more integrated approach that offers patients real choice, and can combine financial savings with quality.

Commissioning in the English NHS was born officially in 1997, when the new Labour government dropped the previous Conservative government's term "purchasing," explains Paton.

The aim was to signal that the culture of the competitive market was being replaced with collaboration between purchasers (health authorities, from 1997 to 2001) and providers (hospitals, mental health services, and community services), although the structure of the market - the split between purchaser and provider - remained. From 2002 the market was revived and commissioning became part of the new market.

According to a recent report from the House of Commons' Health Select Committee, the costs of commissioning are now 14% of the NHS budget.

Paton discusses the options recently advocated by the Nuffield Trust and King's Fund, but says they would be "complex and incur high costs. "They would also retain the purchaser-provider split, which he believes is "yesterday's dogma rather than a necessity."

Paton also challenges the widely held view that primary care trusts cannot control powerful hospitals, referrals, and admissions. And suggests that commissioning attracts a lower calibre of manager than hospitals because it is divorced from provision.

He believes that the major challenge for the NHS now is to combine financial savings with quality. But, he warns, "this cannot be achieved with commissioners who are distinct from the doctors and hospitals that provide care."

He argues that in many areas of England, "primary care trusts and hospitals seek to make financial savings at the expense of others" and says "it is ironic that many of the policy analysts who advocated the purchaser-provider split are now supporting integrated care."

Integrated health authorities (what we now call local health economies) and patient choice are perfectly compatible, he concludes, as long as such authorities are funded in line with their workload. Indeed, this removes the bureaucracy from the current choice policy in England, where the market is seen as such a high priority.

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