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Chapter 2 provides the context, setting out the organisation and governance of commissioning in the NHS. It includes a short summary of the architecture of commissioning pre-Health and Social Care Act (HSCA12), and highlights the important changes which were brought about by the Act, including the abolition of Primary Care Trusts and Strategic Health Authorities, the establishment of Clinical Commissioning Groups (CCGs), the creation of NHS England, transfer of commissioning responsibilities to different bodies (e.g. public health) and the setting up of local Health and Wellbeing Boards. The chapter also highlights the programme theories underlying the HSCA12, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning.

Chapter 7 develops a new framework for the commissioning of ethical care with several components: ethical business commissioning; commissioning local and small; commissioning personally; and commissioning for wellbeing.

The NHS is divided into a purchasing arm, which commissions, monitors, and pays for care; and a provider arm, which delivers care in hospitals and the community. This chapter discusses the importance of establishing sound processes for relationship management and communications between these two organizational arms for efficient NHS organization and care delivery. The relationship between providers and commissioners is structured through a series of timetabled meetings throughout the year. Commissioning for Quality is now central to the relationship between purchasers and providers with financial incentives to provide high-quality, safe care through Commissioning for Quality and Innovation (CQUIN).

This chapter introduces PRUComm, the English national policy research unit in commissioning and the healthcare system funded by the Department of Health and Social Care Policy Research Programme and itsresearch programme on that subject. It then discusses the concept of commissioning in respect of healthcare in the English National Health Service. The theoretical basis for the research, being principally realist approaches to policy analysis; socio legal theory and institutional economics is then expounded and related to the research. Each subsequent chapter is then summarised.

Chapter 3 deals with the development and early operation of Clinical Commissioning Groups (CCGs) of GPs. Building upon the context set out in chapter 2, we examine the factors affecting early CCG development, highlighting the complexity of their governance structures, approaches taken to engaging with their members and the development of external relationships with a wide range of new bodies. We found an explicitly ‘bottom up’ approach to policy implementation, with CCGs given considerable lee-way in developing their structures and processes. As a result, the history of previous commissioning structures and arrangements played an important role in the development of each CCG, as did the approach taken by local leaders and by the PCT/ developing NHS England local team. Engagement with local bodies such as Health and Wellbeing Boards and Local Authorities were also significantly affected by local history and geography. We found that the approach taken by NHS England to CCG development, with early freedom to develop as they chose increasingly curtailed by more prescriptive guidance and a complex assurance regime, led to some frustrations for those involved.

Chapter 4 looks at the evidence about clinical engagement in primary care-led commissioning. Extending and strengthening clinical leadership was one of the key elements of the HSCA12. However, this idea was not new, and this chapter reviews the evidence on the role of clinicians in primary care-led commissioning and how this has contributed to the delivery of healthcare services since the early 1990s. It examines the nature of clinical engagement/involvement in the various primary care-led commissioning models that have been introduced into the NHS. Drawing on a review of the literature and our research on Clinical Commissioning Groups the chapter shows how the extent of clinical engagement has varied between the various schemes. GP commissioners have historically been more successful in influencing the work done by GP practices than in making broader changes to services provided by secondary care. The chapter goes on to explore the claims made both by those involved and in official documents about how greater involvement of clinicians in CCGs – and in particular GPs – will enhance commissioning practice. We test this against evidence from our study of CCGs, showing how the engagement and involvement of GPs requires careful attention to detail. Using a realist approach to evaluation, we highlight the contexts and mechanisms associated with successful – and unsuccessful – GP involvement in commissioning.

Chapter 5 reports research on the more recent policy of allowing CCGs to commission primary care services. In 2014 CCGs were invited to volunteer to take on responsibility for commissioning services from their member GP practices in addition to their wider responsibilities for commissioning acute and community services. In this chapter we explore the history of primary care commissioning and financing in England, and discuss the broad policy objectives which underpinned this significant change in CCGs role and scope. These objectives include the need to move to a ‘place-based’ approach to commissioning, and the need for a more effective linkage between the commissioning of primary and secondary care services in order to support movement of services into the community. Over time, most CCGs have moved to take on full delegated responsibility for commissioning GP services, and have established functioning primary care commissioning committees, with little evidence of significant problems associated with conflicts of interest. The development of local additional ‘quality contracts’ and investment in infrastructure and premises have been important issues, with few CCGs seeking to establish larger scale contractual changes. There have been significant local legacy issues in some areas relating to unclear contracts and poor handover of responsibilities from NHS England. The current legislation, under which statutory responsibility for commissioning primary care services remains with NHS England and is delegated rather than transferred to CCGs, presented some problems, particularly for those CCGs who wished to work together across a broader geographical footprint.

Chapter 6 reports a longitudinal study of commissioners’ (and providers’) use of competition and cooperation. This chapter reports research which aimed to investigate how commissioners in local health systems managed the interplay of competition and cooperation in their local health economies, looking at acute, mental health and community health services. The understanding of the regulatory context of the NHS market by both commissioners and providers of care was unclear. There were differences between local areas in terms of the volume and mode of using competition as a commissioning mechanism, with some having more enthusiasm for and experience in running competitive procurements than others. Commissioners noted that the procurement process was very resource intensive. By 2018 there was a marked decline in the appetite to use competition, especially for large scale service reconfigurations. Collaborative planning involving key local providers was a preferred way for CCG commissioners to approach large commissioning tasks.

Chapter 8 reports research on the changing role of commissioning in the restructured public health system. The chapter will discuss how public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. It will focus on discussing how the re-organisation substantially changed the way public health commissioning is done, who is doing it, and what is commissioned, since the reforms. There have been significant changes in commissioning processes, with important consequences for what health improvement services are ultimately commissioned. Also new opportunities for creativity and joining public health with wider determinants of health (e.g. housing and leisure).

Chapter 9 draws together key themes arising from the book about issues raised by commissioning in the context of a quasi-market for healthcare in the English NHS, such as governance and accountability, clinical engagement, co-ordination and fragmentation. The chapter presents an overview of how commissioning in health and healthcare has developed since 2010 and what the implications are for the future in the light of recent developments moving away from market style mechanisms to forms of local collaborative planning.

Chapter 3 looks at dilemmas in commissioning. Now that the ‘purchaser-provider split’ is entrenched, what judgement can we make of how well commissioning has lived up to expectations? How is the concept being understood and interpreted? What are its strengths and weaknesses?

This introductory chapter sets out the context and significance of this book. Focusing on a decade of austerity, 2008-2018, the challenges facing children’s charities are effectively pushing the sector to crisis point. State funding is reducing whilst demand for services is increasing. This chapter provides an overview of how charities have sought to navigate these testing times.

Chapter 5 concentrates on voices from the frontline and their lived experiences. Within this chapter we focus on the lived realities of commissioning. Commissioning, the central process for managing relationships between the voluntary sector and the state, is one of the most contentious issues for modern day children’s charities. Early intervention and preventative services for children, sit central to this debate – these statutory services at the heart of local government are often commissioned out to voluntary sector organisations for delivery, and form the very focus of this book. We argue that Commissioning in its current form is failing; it threatens the very survival of local voluntary sector organisations seeking to support children and young people, and, rightly so, is coming under increasing scrutiny. High profile cases such as the demise of the charity Kids Company, led by the charismatic Camila Batmanghelidjh, have brought the relationship between the State and sector to the fore of public and academic debate. In this chapter we begin to unpick some of that debate, examining what has happened over the past decade, charities experiences and how we may potentially move forwards.

In chapter 6 we explore the impact of commissioning and policy changes on early intervention and preventative services for children delivered by the charitable sector. The definition of early intervention and preventative services is highly contested and politicised within policy and commissioning processes. This reflects an ongoing debate regarding the shifting paradigm of prevention. As the commissioning narrative has developed, there has been an overall disengagement between the voluntary sector providers and State. As the charitable sector is increasingly exposed to intensifying marketization, polarisation of relationships increases. We identify here three ‘types’ of organisational responses to this ever-changing environments; conformers – those charities who align themselves close to the State and regularly reinterpret their mission to fit State logic; the outliers – those charities which reject State approaches to early intervention and seek to deliver services completely independently of the State; and the intermediaries – those charities which walk between conformity and dissent, working with the State when necessary or too their advantage, and walking away when not. We discuss how these types fundamentally alter children’s charities perspectives and experiences of commissioning and the impact this has on their wider work.

One of the key elements of the Health and Social Care Act 2010 (HSCA 2012) was the transfer of responsibility for commissioning healthcare services from managerially led Primary Care Trusts (PCTs) to newly established Clinical Commissioning Groups (CCGs), led by General Practitioners. In this chapter, the authors explore what can be learned from previous attempts to involve GPs in commissioning care. They then apply that learning to the provisions of the HSCA 2012, highlighting the correspondences and discontinuities between what is known from history and what was proposed. They then present evidence from their research on CCGs, exploring what happened in practice when CCGs were established. Finally, the authors discuss the continuing evolution of health policy in the UK in the light of both historical evidence and their current findings.

In Chapter Three, Elke Heins examines NHS reforms in relation to primary care and commissioning, principally through the government's Health and Social Care Act 2012. Taking effect in April 2013, the act reorganises the way that NHS services are commissioned. At a time when marketised ‘new public management’ experiments are being questioned by many governments around the developed world, the UK government is establishing a regulated market in which ‘any qualified provider’ from either the public or private sectors can compete for the right to be an NHS provider. Heins argues that this development needs to be understood in its historical context, with past marketisation measures having achieved at best ‘ambivalent’ outcomes. In the case of the 2012 Act, given growing budgetary pressures, doctors are likely to outsource their new-found ‘decision-making powers’, given to them in the market context, to private providers where possible.

The chapter covers the author’s first experiences of being at a film pitching session in Australia, and goes on to illustrate how best to pitch in today’s competitive world. Though written with much humour and extensive use of amusing anecdotes, the chapter if full of very sane advice in approaching one of the essential tools for bringing a film to market

A major innovation in public sector commissioning in recent years is the recourse of the state to so called ‘Outcomes-based Contracts’ particularly Payment by Results (PbR) in the UK. A PbR contract contains three elements, a commissioner, a service provider and an outcomes metric. The outcomes metrics is designed, in theory, to align the incentive structures of the commissioner and the service delivery agency so as to achieve efficient results. Thus, PbR is theorised to allow public commissioners to pay a provider of services on the basis of specified outcomes achieved rather than the inputs or outputs delivered. A related innovation is that of Social Impact Bonds (SIBs). SIBs are distinguished from PbR contracts in that they supposedly allow financiers to contribute to the social innovation process by providing working capital. The return on the SIB is calculated using PbR methodology. Compared to a PbR contract, the SIB contract seeks to align the incentive structures, not only of commissioners and providers, but also financiers through an appropriate metrics-based payments scheme. PbR and SIBs have been referred to as key tools for delivering change. In this chapter we set out the theoretical and practical challenges arising from the development and application of PbR and SIBs and consider the evidence of their efficacy or otherwise.