Entire NHS commissioning system may need to be scrapped, MPs say

BMJ 2010; 340 doi: (Published 30 March 2010) Cite this as: BMJ 2010;340:c1792
  1. Adrian O’Dowd
  1. 1London

    Commissioning in the NHS in England has been a 20 year long “costly failure” and may need to be scrapped, MPs have concluded.

    After its recent inquiry the parliamentary health select committee published a highly critical report on commissioning on 30 March. The report gives its verdict of almost two decades of NHS commissioning in England since purchasers and providers were split in 1991.

    The MPs said that primary care trusts were not commissioning effectively, were too passive, and lacked the clinical knowledge and other skills to challenge hospitals over the provision of services.

    Frequent reorganisations in the NHS and a high turnover of staff had worsened the situation, they said.

    The committee questioned whether the government’s “world class commissioning” initiative, designed to improve the quality of commissioning, will work. The report says: “There are concerns that WCC will be no more than a ‘box ticking’ exercise whereby people expend a lot of energy merely demonstrating they have the right policies in place, rather than actually transforming patient outcomes and cost effectiveness.”

    As part of its inquiry the committee commissioned the National Audit Office to conduct a telephone survey of commissioners, which showed that trusts themselves thought they were doing a good job. However, the committee said that trusts’ positive perceptions of commissioning were significantly at odds with extensive evidence received by the committee that pointed to weaknesses in the system.

    Primary care trusts need a more capable workforce, higher quality management, the ability to attract talent, and more power to deal with providers, says the report. But this could prove difficult, given that the government has announced a 30% reduction in management costs in primary care trusts and strategic health authorities from 2010 to 2013.

    The report recommends that the Department of Health commission a study of what levers should be introduced to enable trusts to motivate providers of services better and to review contracts with providers so that they have fixed and enforceable measures of quality and efficiency written into them.

    The committee cautioned against relying on management consultants to strengthen commissioning.

    “Whatever the benefits of the purchaser-provider split, it has led to an increase in transaction costs, notably management and administration costs,” says the report. “Research commissioned by the Department of Health but not published by it estimated these to be as high as 14% of total NHS costs.”

    The committee said it was dismayed by the department’s failure to provide clear and consistent data on the overall bureaucratic costs of commissioning.

    It warned that the commissioning system may need to be dropped entirely, saying, “If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser-provider split may need to be abolished.”

    Kevin Barron, the committee’s chairman and Labour MP for Rother Valley, said, “It is a sorry story if, after 20 years of attempting to operate commissioning, we remain in the dark about what good it has actually done.

    “The government must make a bold decision. If improvements fail to materialise it could be time to blow the final whistle.”

    A health department spokeswoman said: “Commissioning is improving, and there are many examples of primary care trusts across the country making a difference for their patients by investing in better quality, better value, and better designed health care. Commissioners have a valuable role in helping shape more personalised and efficient care for their local populations by continuously reviewing services.”

    She added that the introduction of world class commissioning in 2007 had been the first major step in transforming trusts’ commissioning skills and was showing encouraging signs in its second year.


    Cite this as: BMJ 2010;340:c1792