Analysis And Comment Health policy

A new look at NHS commissioning

BMJ 2007; 334 doi: (Published 04 January 2007) Cite this as: BMJ 2007;334:22
  1. Joan Higgins, emerita professor of health policy
  1. 1University of Manchester, Manchester
  1. Withington, Manchester M20 3LD joan.higgins{at}
  • Accepted 30 October 2006

With NHS reforms seemingly having gone full circle, it is time for the government to break out of the loop

The NHS is being restructured to make health service commissioning the engine of change. However, the model that has been developed builds on a legacy of weak incentives and lack of imagination. It has focused on modifying existing organisations and changing boundaries based on geography. It does not tackle the fundamental flaws inherent in the system created in the 1990s or respond to some key questions that most other healthcare systems have confronted over the past 70 years. This paper challenges the basis on which the NHS is developing commissioning and suggests five areas for further thinking.

Current strategy

The annex to Health Reform in England: update and commissioning framework 1 published in July 2006 sets out the vision for commissioning in England over the next few years. Although some new techniques are proposed, the plans described are essentially more of the same and provide little reassurance that commissioning really will be given the levers to secure appreciable improvements in health or health services. Five assumptions in the current thinking need to be challenged:

  • That patient choice should primarily be about choice of provider rather than commissioner

  • That commissioning organisations need to be defined by geography and resident population

  • That purchasers can and should commission on a population basis rather than on behalf of individuals

  • That general practitioners and primary care trusts should be the only commissioners and that delegating commissioning functions to other organisations necessarily means privatising commissioning

  • That developing specialised commissioning organisations would undermine the commitment to a tax funded NHS and pave the way for an insurance based model.

Choice of provider or commissioner?

The original idea for a purchaser-provider split in the NHS came from Alain Enthoven in 1985.2 He argued that …

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