Intended for healthcare professionals


Commissioning in the English NHS

BMJ 2010; 340 doi: (Published 15 April 2010) Cite this as: BMJ 2010;340:c1979
  1. Calum Paton, professor of public policy
  1. 1Keele University, Keele, Staffordshire ST5 5BG
  1. c.paton{at}

    A failing system that needs to be abandoned

    Commissioning in the English NHS was born officially in 1997, when the new Labour government dropped the previous Conservative government’s term “purchasing.” The aim was to signal that the culture of the competitive market was being replaced with collaboration between purchasers (health authorities, from 1997 to 2001) and providers (hospitals, mental health services, and community services), although the structure of the market—the split between purchaser and provider—remained. From 2002 the market was revived and commissioning became part of the new market.

    Commissioning can be interpreted in two different ways. To some, it means collaboration between commissioners (primary care trusts and their associated general practices) and providers to determine healthcare needs and how to provide them in an affordable way. To others, commissioning is the means by which providers are disciplined—a view embraced by the Department of Health’s “world class commissioning” initiative, which is geared to making primary care trusts a meaningful countervailing power to hospitals.

    Since the original “internal market” in the NHS, introduced in 1991, purchasing or commissioning has mutated through a series of confusing and frequent reorganisations, involving mutually incompatible policies and high costs.1 According to one recently published report from the House of Commons’ Health Select Committee,2 the costs of commissioning …

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