World class commissioning: a health policy chimera?

The health reforms in England have entered a phase in which greater emphasis is being placed on market-like mechanisms. The ability of the commissioners of care to negotiate on equal terms with providers will be of critical importance in the emerging market. The government has set out plans to develop 'world class commissioning' and this essay reviews experience in Europe, New Zealand and the United States to understand what is involved in working towards this goal. The evidence reviewed shows that in no system is commissioning done consistently well and highlights the obstacles to the development of world class commissioning. The reasons for this centre on the complexity of health care and the inherent difficulty of commissioning health services in publicly financed systems. Commissioners will need to be able to access a range of expertise and are likely to incur significant expenditure in so doing. There are warning signs from other systems of health reforms that result in adversarial and legalistic approaches, and do not give sufficient attention to relational contracting. Even if world class commissioning is developed, it may fall short of its potential in the absence of other changes in the design of the reforms, such as autonomous providers and appropriate payment systems. In view of these challenges, a more promising alternative would be to develop competing integrated systems.