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The current government has given priority to two different objectives in reorganizing the National Health Service (NHS) in England and Wales. The first objective is to create a primary care-led NHS by organizing commissioning of hospital and community health services by new primary care organizations. The second objective is to improve quality and performance in the NHS and to assess this using evidence in various ways. Previous research has suggested that the changes GPs wish to make to services are often not based on published evidence. This suggests a conflict between the two principal objectives intended to drive the reorganization of the NHS. The aim of this study was therefore to explore these issues further. An interviewer-administered questionnaire survey was conducted on one general practitioner and one public health physician from each of four total purchasing pilots (TPPs) in Wales and their four host health authorities, respectively. The main outcome measures were the types of evidence used, and the extent to which evidence impacted on decisions. Access to evidence and views about its usefulness are also reported. It was found that more high-quality evidence was used in support of disease-specific than in support of non-disease-specific changes to care. Evidence played a greater role in decisions to change services that were purchased by health authorities, or provided by TPPs, than it did in changes to services purchased by TPPs. Similarly, higher quality of evidence was used when making decisions to change services that were purchased by health authorities or provided by TPPs, than for services that were purchased by TPPs. It is concluded that there is a mismatch between the availability of conventional, disease-specific evidence directed at the delivery of care, and the need for other kinds of evidence for commissioning changes in the organization of care. This means that we need research and development to develop new methods and new types of evidence so that we can assess the benefits of commissioning in a primary care-led NHS.
