Governance needs balance of trust, challenge and workarounds

balancing different elements


Another interesting read from the NIHR Journals Library – this report focuses on governance and commissioning practices, based on research undertaken by an interdisciplinary team from a number of academic institutions.


The research addressed a number of important questions, including:

  • How do English health policy-makers and NHS commissioners understand the policy aims of commissioning, and how can governance be exercised over providers through commissioning?
  • How far does current commissioning practice allow commissioners to exercise governance over their local NHS health economies?
  • What factors, including the local health system context, appear to influence commissioning practice and the relationships between commissioners and providers?


The research team undertook at mixed methods realistic evaluation, incorporating:

  • analysis of policy documents, speeches and interviews;
  • cross-sectional analysis of data to explore associations between characteristics of commissioners and service outcomes;
  • case studies in four areas in the English NHS;
  • comparative analysis with models in Germany and Italy;
  • action learning sets for managers and GPs in the case study sites and with the comparison sites in Germany and Italy.


From analysis of key policy documentation, the research team developed a model of the underlying programme theory of NHS commissioning policy (in England) from 2010-2012, expressed concisely as a series of assumptions (page 37), tested through the study. Essentially (but unsurprisingly!), the research team found a gap between policy-makers’ assumptions and actual commissioning practice – perverse incentives and barriers often constrain commissioners’ ability to influence individual providers and the overall market.

A key finding  is that commissioners are “decoupling” the financial and clinical aspects of provider management and negotiation, due to the financial pressures inherent in the system.  There are also questions around how much patient choice is influencing provider performance and sustainability, challenging the assumption that patient selection or deselection of providers will lead to improved health outcomes.

The study also suggests that more involvement of GPs in commissioning is leading to care pathway redesign but as yet, limited decommissioning. Admittedly, clinical commissioning groups were in their infancy when the study was conducted so it’s possible strategies and approaches have since matured.

Some other interesting findings from case studies include:

  • Some managers lacked technical expertise to be able to write service specifications and to interpret performance data.
  • GPs and consultants were sometimes able to resolve practical issues around patient pathways.
  • Tariffs were found to weaken commissioners’ control of costs and activity and a typical response was to bundle tariff payments.
  • The risk of destabilising local providers leads to a reluctance to fully exploit competition.
  • Provider management involves a number of trade-offs:  such as, trust and challenge; complete contracts and flexibility of provision.
  • Commissioners reported limited flexibility in managing providers with regards to transparency of activity; nudging lifestyle changes; provider-led service change; provider implementation of changes agreed.
  • However, commissioners also reported being able to influence providers with regards to: referral rates; service specifications; and models; costs through block contracts and bundling; target monitoring.
  • Commissioners were able to develop “adaptive commissioning practices”, with some control over: which patient groups to prioritise for service redesign; stakeholder engagement; redesign through micro-commissioning; using incentives; and identifying opportunities.
  • Typically, the more complex the pathway (case mix, number of agencies involved, uncertain outcomes), the more likely commissioners are to “commodify” standardised, discrete care packages.
separate negotiations

Findings suggest that financial and contracting negotiations are separated, with clinicians less likely to be involved in financial discussions


I wasn’t completely clear who the main audience of the report is (the report is possibly a little long and heavy reading for most busy commissioners) but there are some important messages here for national bodies and policy-makers, particularly in relation to empowering commissioners to deliver service transformation.

With an increased focus on system level transformation, it may be timely to consider how local health systems can be supported in developing effective governance across multiple agencies, with different objectives and regulatory requirements.

From a commissioner perspective, there may be some practical points to consider. The final report suggests that involvement of GPs in financial decision making could benefit from more opportunistic involvement of GPs who have an interest in a particular policy or service area; however, it does advise representative involvement of senior clinicians, not least because clinical opinion is often perceived higher than non-clinical managers’ opinions.

Commissioners may wish to consider how they capture and effectively utilise expertise (clinical and non-clinical) to design, implement and monitor change.


The research highlights the need to balance different approaches – trust; challenge; and workarounds – to manage provider relationships


Sheaff, R et al (2015) NHS commissioning practice and health system governance: a mixed-methods realistic evaluation, Health Services and Delivery Research, 3 (10)

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