Education And Debate The NHS revolution: health care in the market place

Practice based commissioning: applying the research evidence

BMJ 2005; 331 doi: (Published 08 December 2005) Cite this as: BMJ 2005;331:1397
  1. Judith Smith, senior lecturer (,
  2. Jennifer Dixon, director of policy2,
  3. Nicholas Mays, professor of health policy3,
  4. Hugh McLeod, research fellow1,
  5. Nick Goodwin, senior lecturer3,
  6. Siobhan McClelland, external professor4,
  7. Richard Lewis, senior fellow in health policy2,
  8. Sally Wyke, professor of health and social care5
  1. 1Health Services Management Centre, School of Public Policy, University of Birmingham, Birmingham B15 2RT
  2. 2King's Fund, London W1G 0AN
  3. 3Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  4. 4Health Policy and Economics, Health Economics Research Unit, School of Care Sciences, University of Glamorgan, Glamorgan
  5. 5Department of Nursing and Midwifery, University of Stirling, Stirling FK9 4LA
  1. Correspondence to: J Smith

    General practitioners are being asked to retake responsibility for commissioning healthcare services. What can we learn from previous experience?


    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 …

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