Special issue on commissioning

There has been a sustained push to introduce market and quasi market mechanisms to improve the quality and efficiency of health and community services over the past 30 years. The radical shift in the market began during the Thatcher and Reagan governments in the United Kingdom (UK) and the United States (US) in the 1980s.

Criticisms of traditional models of government service delivery centred on perceptions of excessive bureaucratisation, inefficiency and lack of responsiveness to consumer needs when government both funds and delivers services (Osborne and Gaebler 1992). In response, heavy emphasis was placed on separating planning, regulation and purchasing from the provision of services through privatisation and competition, with the intent of driving improvement.

In practice, the separation of functions led to a new set of problems. Specifying services and outcomes in contracts proved more difficult than had been expected. Transaction costs went up. Existing service systems were disrupted. Longstanding collaborative relationships broke down. Risks to access emerged. Contract management and evaluation were challenging. Provider markets were underdeveloped (Glasby 2012).

More balanced models that combined market mechanisms with stronger roles for government were subsequently promoted by the Blair and Clinton administrations and pursued by the Hawke government in Australia during the 1990s. More emphasis was placed on separating the purchase of services from their provision. Less emphasis was placed on wholesale privatisation and competition. Increasingly, there is more concern with the quality and outcomes of the services provided than with whether they are delivered by the public or private sector. In response, health and community services organisations have become more accustomed to the need to demonstrate the quality and efficiency of their services.

The UK has further separated out health system functions through the introduction of various forms of commissioning organisations. Government retains overall responsibility for policy, funding and regulation, while devolving planning, purchasing, management and evaluation to commissioning bodies for geographically defined populations. In turn, these commissioning bodies contract private, public and non-government agencies to deliver the required services. In theory, government holds the commissioning bodies accountable for the outcomes in their catchment and the commissioning bodies hold providers accountable for their performance in delivering services. Despite the long history of commissioning in the UK there remains significant challenges in its implementation and in realizing improved service delivery as a result (Addicott 2015).

In Australia, the Commonwealth, state and territory governments are showing considerable interest in commissioning models. Several state and territory jurisdictions are beginning to contract organisations to commission services for catchment areas. The Commonwealth intends to develop the newly established Primary Health Networks as commissioning agents for service delivery for their catchment populations (Booth and Boxall 2015); the extent of their role is not yet clear.

With commissioning becoming more prevalent, it is worth reflecting on what has been learnt along the way. The planning, purchasing, management and evaluation functions central to commissioning have been applied in a variety of models. Some approaches have proved more effective and robust than others.

This special issue provides perspectives on commissioning from Australia (for example, see Carlisle et al. 2015; Joyce 2015; and O’Brien et al. 2015), the UK (Addicott 2015), New Zealand (Cumming 2015) and China (Lin 2015). It covers conceptual frameworks for commissioning, the history of commissioning and the experience of commissioning in particular jurisdictions and settings. Specific applications of commissioning for general practice, capacity building and community services are also included.

Commissioning is a means to an end, not an end in itself. It may have potential as a mechanism for improving the quality and efficiency of health and community services. However, there are many pitfalls and risks; the choices made in how commissioning is developed and implemented in Australia will determine just how many of these are avoided. It is worth learning from past experience.