Introduction

The English NHS is unusual in its continuing faith in primary care based organisations to carry out effective purchasing of healthcare services. The latest incarnation of this approach is to encourage all general practices to be responsible for a budget to purchase community health services and secondary care on behalf of their enrolled populations by the end of 2006.1 2 The logic is that in doing so, they will act more cost effectively, scrutinising the demand for hospital care and redesigning services across the hospital-community interface. Some evidence supports this logic.3 We assess current policy on purchasing in the light of evidence from research concerning purchasing by primary care organisations in the 1990s and more recent evaluations of primary care groups and trusts and draw out some key messages that may be helpful in its further development.

Commissioning by primary care

Purchasing is typically considered to be a process whereby services are specified upfront on the basis of quality and value for money, with only those who can meet such requirements tendering to provide the service.3 Commissioning is used to describe what is arguably a more sophisticated and strategic process of assessing health needs, developing new services or providers to meet those needs if required, contracting for services, and undertaking a range of strategic efforts to improve population health.4 We previously defined primary care led commissioning as “Commissioning led by primary health care clinicians, particularly GPs, using their accumulated knowledge of their patients' needs and of the performance of services, together with their experience as agents for their patients and control over resources.”3

Commissioning by primary care, and particularly practice based commissioning (which involves clinicians directly) is a response to …