When the NHS reforms were first implemented in 1991 most emphasis was placed on developing the provider function. Many senior NHS managers opted for operational management, perceiving purchasing as at best uninteresting and at worst trivial and unnecessary. Three years later things look different. The minister of health, Dr Brian Mawhinney, boosted purchasing through a series of three speeches last year,1 and several organisations concerned with health service management now take purchasing seriously.2

In parallel, some far sighted managers and doctors saw the need to develop purchasing by encouraging collaboration between district health authorities and family health services authorities. These “commissioning agencies” began to offer a more coherent view of what commissioning might achieve by overcoming longstanding bureaucratic boundaries. Some of the first developments were in North West Thames and Wessex regions, where the benefits of joint commissioning were recognised early on, and some authorities, such as the Dorset Commissioning Agency, became a role model for others.3,4

Nevertheless, joint commissioning has developed slowly. Reasons for this include the continuing independent statutory basis of both district health authorities and family health services authorities and the substantial effort that running two authorities in parallel entails; the challenge of bringing together organisations at different stages of development; and the need to translate a commitment from top managers to those in more junior management …