3 - England’s health commissioning model

Summary

Aim

This chapter examines the model of commissioning used currently in England. It provides a detailed discussion of the integrated care system established legally in 2022 and all the partner organisations that are required to collaborate to make this approach effective. It also briefly outlines commissioning models in the other countries of the UK, and some international examples, to see how they compare with the model in England.

The commissioning model in England

In the early 1990s, health reforms in England moved to separate the purchasing of services from their delivery. This created an ‘internal market’, meaning health and care providers operate like a business. The intention was to create efficiencies via a more competitive market that has a clear ‘purchaser– provider’ arrangement. Simply put, commissioners purchase services from the health and care providers. This arm’s- length approach was strengthened in 2012 with the finalisation of the Transforming Community Services programme and the implementation of the Health and Social Care Act 2012. Prior to this, the only providers not in a purchaser– provider arrangement were community services, which were entwined with the commissioning bodies, then called primary care trusts. The Transforming Community Services programme sought to separate the community services element from primary care trusts into distinct providers, severing the organisational link. Clinical commissioning groups were then formed, replacing primary care trusts.

The rhetoric for the internal market reforms in the 1990s and 2012 was about improving quality with new arrangements that would be more efficient, responsive, and innovative. The BMJ (Moberly, 2018) reported the British Medical Association (BMA) argument that these reforms were more to do with saving money via structural change and greater competition. The BMA made a call to repeal the changes made in 2012, at their annual representative meeting. Segall (2018), in line with the earlier BMA position, argues that this move towards separation was not effective. He notes that the internal market creates higher regulatory and transaction costs, greater fragmentation between services, and more bureaucracy, and that it invites opportunities for privatisation.