1. The future of commissioning
Dr Judith Smith
Director of Policy
The Nuffield Trust
8 March 2013
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2. The story so far
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3. Commissioning in the reformed NHS
• Significant faith continues to be put in commissioning, as
seen with current reforms
• Idea that commissioners can challenge providers and use
contracts to bring about improvements
• Now firmly put into the hands of clinicians
• And this will have to work in a framework of choice and
competition
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4. Is this a triumph of hope over experience?
•Commissioning has struggled to shift care away from
hospitals towards community settings
• It has found it difficult to stem the rise in emergency
admissions
•It has failed to reduce health inequalities in England
• Conclusion of a review of the impact of commissioning
under New Labour (Smith and Curry, in Mays et al, 2011):
‘When weighed against the transaction costs of running a
commissioning system, the verdict would seem to be weak or
at best equivocal.’
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5. Verdicts on commissioning
‘Weaknesses remain, 20 years after the introduction of the
purchaser-provider split. Commissioners continue to be
passive, when to do their work efficiently, they must insist
on quality, and challenge the inefficiencies of providers,
particularly unevidenced variations in clinical practice.
(Health Select Committee Inquiry 2010, p38)
‘The experience of Stafford shows an urgent need to
rebalance and refocus commissioning into an exercise
designed to procure fundamental and enhanced standards
of services for patients, as well as to identify the nature of
the service to be provided.’
(Francis Inquiry report, para 1.35) © Nuffield Trust

6. Do we know what commissioners
actually do?
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7. New Nuffield Trust research for NIHR (Smith et al,
2013)
• Two-year (2010-2012) in-depth study of three primary care
trusts and their GP commissioners, and how they
commissioned care for people with long-term conditions
• Commissioning observed to be a very labour-intensive
activity
• Characterised by much more relational work (e.g.
Developing collaboration and consensus with providers)
than harder edge ‘transactional’ work
• Commissioners act as the convenor of the local system
• Commissioning work often focused on relatively marginal
service changes
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8. • Effort involved in this labour of commissioning did not
always seem proportionate to improvements in services
• Commissioners struggled to describe the outcomes they
were seeking to achieve
• Financial matters seemed frequently peripheral to
commissioning discussions
• Effectiveness of commissioning significantly hampered by
periodic reorganisation
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9. What does this mean for the future
of commissioning?
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10. 'Commissioning by Clinical Commissioning Groups will, in two years, result in
higher quality, more efficient health care than commissioning by primary care
trusts today'. How far do you agree with this statement?
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11. 'Commissioning by Clinical Commissioning Groups will, in two years, be more
effective than primary care trusts have been in breaking down the barriers
between primary and secondary care'. How far do you agree with this statement?
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12. We need to decide what we want CCGs to do
• Confidence is lacking re their ability to secure higher
quality and more efficient services
• But there is optimism about their ability to bring about
improvements in co-ordination of services across primary
and secondary care
• When taken alongside the evidence of commissioners
preferring relational and collaborative work, what do we
want of CCGs?
• Should they focus on developing integrated delivery of
care for long-term conditions, urgent care, children and
older people?
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13. We need to decide what commissioning is to be
• It would seem to be time to develop new smarter
arrangements that offer other ways of sharing service and
financial risk with providers
• And if commissioning is to be really about quality as well
as cost, much richer and more timely data will be needed,
both quantitative and qualitative
• This can really play to the strength of local clinicians
leading the planning and funding of care
• So will the CCG be a local service development and
improvement organisation?
• And how will it do this whilst shaping a local NHS market
through the use of contracts? © Nuffield Trust

14. Acknowledgement and disclaimer
This project was funded by the National Institute for Health Research
Health Services Delivery Research programme (project number
08/1806/264).
The views and opinions expressed therein are those of the authors and
do not necessarily reflect those of the NIHR HSDR programme or the
Department of Health.
© Nuffield Trust