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

Open Access Open Badges Research

How managed a market? Modes of commissioning in England and Germany

Rod Sheaff1*, Naomi Chambers2, Nigel Charles1, Mark Exworthy3, Ann Mahon2, Richard Byng4 and Russell Mannion5

Author affiliations

1 University of Plymouth, UK

2 Manchester Business School, UK

3 RHUL, London, UK

4 Plymouth University Peninsula Schools of Medicine and Dentistry, UK

5 University of Birmingham, UK

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Citation and License

BMC Health Services Research 2013, 13(Suppl 1):S8  doi:10.1186/1472-6963-13-S1-S8

Published: 24 May 2013



In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control ('media of power') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so.


Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources.


The comparison exposes and contrasts two basic generic modes of commissioning:

1. Surrogate planning (English NHS), in which a negotiated order involving micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers.

2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power.


Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control.