“Surgeons and commissioners used a different language when they met” according to project findings

Cartoon people standing on a pie chart

Importance of involving surgeons in the commissioning decision-making process

Rational commissioning

This report describes a project, led by Right Care, to involve surgeons in the commissioning decision-making process, because observations made by the Department of Health and Surgical Specialty Associations showed that there were inconsistencies in the rates of elective surgical procedures between Primary Care Trusts, and that sometimes existing surgical procedures were “classified as being of low clinical value”. It was felt that commissioning decisions made locally could increase variation in service delivery, and also cause conflict with secondary care clinicians, such as surgical staff.

The project had three objectives for the improved delivery of surgical services:

  1. To reduce unexplained variations
  2. To reduce geographical variation
  3. To provide evidence based support to commissioners of elective surgical procedures
Cogs working together

Strong partnership ensures engagement and ownership


In order for these objectives to be met and to ensure engagement and ownership, key stakeholders formed a partnership, comprising representation from the Royal College of Surgeons England, the Surgical Specialty Associations, and the National Institute for Health and Clinical Excellence. To ensure consistency, a manual was written setting out the processes involved and by signing up to this manual, all members of the partnership have agreed to produce guidance which:

  • Provides evidence-based high-value care pathways on surgical intervention to commissioners
  • Highlights variations in service provision
  • Provides commissioners with measures to help them make commissioning decisions
  • Can be used by the local healthcare community to facilitate change
  • Links to good practice examples, and further information for patients and clinicians about high value care pathways
  • Highlights uncertainties, where there are gaps in knowledge, and makes recommendations for further research
Signpost saying Help and support

Groups produced guidance for commissioners of surgical services

Commissioning guidance

Groups were set up to produce commissioning guidance on a set of surgical interventions for common conditions, such as tonsillectomy, knee pain, and low back pain, conditions that can cause long-term issues for patients and health care organisations. The conditions were selected using a set of criteria, including:

      1. Burden of disease
      2. Clinical priority
      3. Clinical uncertainty
      4. Resource impact on the NHS
      5. Strategic importance

Each group had representation from commissioning, service delivery, and patient groups, and they did not just look at the surgical elements, but at the pathway as a whole.

This guidance produced as a result of this work, is supported by comprehensive literature reviews, and is meant to complement existing clinical guidance, and not to replace it. As a result of the consistent approach by which they have been developed, they have been formally accredited by NICE (National Institute for Health and Care Excellence).


The report suggests that we ‘need to move away from a debate about “rationing” and instead have a debate about “rational commissioning”’. Rationing presents a negative image, one of reducing or taking something away from patients. Rational commissioning suggests that we factor in all stages of the care pathway, so that patients, primary, secondary and tertiary care, are all accounted for in the commissioning decision-making process. This should mean that patients will know what to expect and staff will know what to deliver, wherever they are based geographically and in whichever setting.

Having read this paper, how do you think your organisation could improve the transition between primary care and surgical care? Which of the commissioning guidance would be most useful to your area of specialty? Are there any that you think should also be on the list?


Clinical engagement in high-value commissioning: elective surgical procedures (PDF)
N Beasley
Right Care Casebook Series
January 2013

Further resources

Right Care

Value base clinical commissioning of elective surgical care: Right Care elective surgery project: phase 1 report

National Institute for Health and Care Excellence

Federation of Surgical Specialty Associations

Royal College of Surgeons England

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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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