1 Introduction
1. The Department of Health states that "the
central theme of NHS commissioning" is:
understanding the health needs of a local population
or a group of patients and of individual patients; working with
patients and the full range of health and care professionals involved
to decide what services will best meet those needs and to design
these services; creating a clinical service specification that
forms the basis for contracts with providers; establishing and
holding a range of contracts that offer choice for patients wherever
practicable; and monitoring to ensure that services are delivered
to the right standards of quality.[2]
2. Although the term "commissioning" has
only been in use since the 1990s, the functions it refers to have
been present, in one form or another, since the inception of the
NHS. It has always been necessary to determine the health needs
of the population and to design services accordingly, with due
regard to the available level of resources. The NHS has also always
aspired to ensure that its services meet high quality standards.
3. From 1948 to 1991 the NHS was largely a managed
service, with the notable exception of primary care, which was
provided on a contractual basis by independent practitioners such
as GPs. From 1991 a "purchaser / provider split" was
also instituted in respect of hospital and community services,
with the creation of freestanding NHS Trusts in place of directly-managed
provider units. Despite many changes since then, the purchaser
/ provider split has persisted, with an established consensus
among the three main political parties that such a split is necessary.[3]
4. As the process of contracting for services has
developed, commissioning, in its current form, has become increasingly
important to the effective functioning of the NHS. Despite its
importance, however, there are longstanding and widespread concerns
about how well it is actually done and how much benefit is derived
from the substantial process costs incurred. Throughout two decades
of frequent reorganisation in the structures of the NHS, many
of which were designed at least in part to enhance the effectiveness
of commissioning, this objective has remained largely unfulfilled.
5. The White Paper Equity and excellence: Liberating
the NHS, published on 12 July 2010 sets out the plans of the
Coalition Government to try to improve on this performance. It
contains a further iteration of the structure of commissioning,
based on the creation of General Practitioner commissioning consortia.
6. In the light of the disappointing history of the
development of commissioning, the report of our predecessor Committee
published on 30 March 2010,[4]
and the Coalition Government's White Paper, the Committee announced
on 27 July 2010 that it proposed to undertake a follow-up inquiry,
with the aim of discovering whether the changes proposed by the
Government were likely to learn the lessons of history and deliver
the promise to make commissioning more effective. (Our terms of
reference are set out in full in Annex 1.)
7. During the course of our inquiry, 142 memoranda
of written evidence were received and six evidence sessions were
held. Oral evidence was taken from: officials at the Department
of Health; the Royal College of General Practitioners; the British
Medical Association; the National Association of Primary Care;
the NHS Alliance; individual GPs; academics; the King's Fund;
the Nuffield Trust; Care Trust and Primary Care Trust officials;
the NHS Confederation; National Voices; the Patients Association;
Mind; Age UK; UNISON; the Local Government Association; the Association
of Directors of Public Health; NHS Partners Network; and the Secretary
of State for Health, Rt Hon Andrew Lansley CBE, MP. We thank everyone
who took the time to contribute to our inquiry.
8. We gained many useful insights when we visited
City and Hackney PCT on 14 December, meeting senior staff from
the PCT and East London and the City Alliance, as well as GPs
from the East London Integrated Care consortium. We are most grateful
to all those who took the time to give presentations to us and
answer our questions, to the PCT for arranging the visit and to
the Lawson Practice for playing host to us.
9. Our Specialist Adviser for this inquiry was Kieran
Walshe, Professor of Health Policy and Management at Manchester
Business School, whom we thank for his assistance.[5]
2 Department of Health, Liberating the NHS: Commissioning
for patients, July 2010, para 1.7 Back
3
It is true that by 2002 the purchaser/provider split had been
abolished in respect of community services but the split is actually
now being recreated in this regard, under the Transforming Community
Services programme, with these services once more ceasing to be
directly managed. Back
4
Health Committee, Fourth Report of Session 2009-10, Commissioning,
HC 268-I Back
5
Professor Walshe did not declare any interests. Back
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