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This article is part of the supplement: The Limits of Market-based Reforms

Open Access Research

Commissioning healthcare for people with long term conditions: the persistence of relational contracting in England’s NHS quasi-market

Alison Porter1*, Nicholas Mays2, Sara E Shaw3, Rebecca Rosen4 and Judith Smith4

Author Affiliations

1 College of Medicine, Swansea University SA2 8PP, UK

2 Professor of Health Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

3 Queen Mary University of London, Centre for Primary Care and Public Health, Blizard Institute, 8 Turner Street, London E1 2AB, UK

4 The Nuffield Trust, 59 New Cavendish St, London W1G 7LP, UK

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BMC Health Services Research 2013, 13(Suppl 1):S2  doi:10.1186/1472-6963-13-S1-S2

Published: 24 May 2013

Abstract

Background

Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.

Methods

We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.

Results

In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.

In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.

Conclusions

Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.