What helps and hinders effective commissioning? Experiences from primary care



In England, from April 2013, there will be significant changes to the NHS, particularly with the introduction of 211 clinical commissioning groups (CCGs). These GP-led organisations will take on the responsibility of funding, planning, and obtaining health services for their local areas. It is essential that best practice is applied so that efficient decisions are made to suit the whole population of the area that is being served.

PlanningFor this reason, the Nuffield Trust has published this report, presenting the analysis of research carried out in three primary care trusts – Wirral, Calderdale, and Somerset – to find out how commissioning works in practice, and what influences the effectiveness of commissioning activities for primary and secondary care services at a local level.

The target audience for this report includes commissioners, primary care practitioners, providers, Clinical Commissioning Groups, and anyone else who is involved in making decisions about service provision for NHS patients with long-term conditions.

Cycle of commissioning


The report starts with a brief and useful introduction to commissioning, explaining how commissioners are working from Department of Health guidance, influenced by the Ovretveit cycle of commissioning (published in “Purchasing for health: a multidisciplinary introduction to the theory and practice of purchasing”).

Following this, the authors describe in-depth the research process, explaining how they chose their sites for analysis from a group of high-performing commissioner primary care trusts. They examined the practices of the three trusts for more than a year, gathering qualitative data from interviews, meeting observation, and documents, and quantitative data from activity levels and patient experience.

Chronic diseaseCommissioning for long-term conditions

The report focused on the commissioning of care for people with long-term conditions, looking at diabetes across all three sites for comparison purposes, and then dementia in Calderdale and the Wirral, and stroke in Somerset.

The backgrounds and commissioning structure for each Trust are described and illustrated with tables so that it is easy to see the similarities and differences between each Trust. The Primary Care Trusts each identified specific areas of commissioning activities for analysis. For example, Calderdale provided details of their strategic review of dementia services, while Somerset offered early supported discharge service for stroke, and the Wirral, their memory assessment service.

Main themes of the research

The authors of the report identified the following seven themes:

  1. Scope of commissioning
  2. Labour of commissioning
  3. Identifying the commissioners
  4. Question of money
  5. Scale and pace of change
  6. Directives and guidance for commissioning
  7. Working in a context of uncertainty

These themes are analysed in much greater depth in the full report.

Overall findings

The broad findings from their research demonstrate that current practices, with regards to commissioning and long-term conditions, differ from the “competitive and market-focused approach” initially intended by the NHS. However, the analysis shows that their local commissioning practices are effective, and this is due to a number of factors, further described in the Discussion section of the report.


This report is based on research evidence and in-the-field experience, providing useful background to the evolution of commissioning and next steps for improvement to commissioning activities.

It is always useful to have models of good practice when embarking on a new initiative, and this research provides this. It includes examples of what commissioners can expect, and how to manage priorities, relevant measures for the collection of effectiveness data, and recommendations for what is needed from the NHS Commissioning Board. It is a succinct document, but provides clear advice on how to manage the commissioning process for long-term conditions.

Looking at the factors which led to the success of these initiatives, are these things that you have thought about in your own practice? Do you have others to add? It would be good if people could share their own commissioning success stories here, so that we can continue to share experience and build on good practice.


Commissioning high-quality care for people with long-term conditions
J Smith, A Porter, S Shaw, R Rosen, I Blunt, N Mays
Nuffield Trust
March 2013

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Caroline De Brún

Caroline De Brún

Caroline has been a medical librarian in a variety of NHS and academic roles since 1999, working in academic, primary and secondary care settings, service improvement, knowledge management, and on several high profile national projects. She has a PhD in Computing and currently develops resources to support evidence-based cost and quality, including QIPP @lert, a blog highlighting key reports from health care and other sectors related to service improvement and QIPP (Quality, Innovation, Productivity, Prevention). She also delivers training and resources to support evidence identification and appraisal for cost, quality, service improvement, and leadership. She is co-author of the Searching Skills Toolkit, which aims to support health professionals' searching for best quality clinical and non-clinical evidence. Her research interests are health management, commissioning, public health, consumer health information literacy, and knowledge management. She currently works as a Knowledge and Evidence Specialist for Public Health England, and works on the Commissioning Elf in her spare time.

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