Commissioning decisions are influenced by each of the governance dimensions outlined in the previous chapter, while the commissioning process itself can provide a route for involving communities and for making services more accountable. The extent to which underlying governance principles, such as social equity or accountability, are reflected in national policies and in governance arrangements will influence decision making at a local level, as will the importance attached nationally to the prevention of ill health. However, even where there is national policy commitment, to social equity for example, this may be imperfectly translated into local practice. There is room for manoeuvre over the relative emphasis accorded to each phase of a commissioning cycle, over the extent to which health equity is built into contracts with providers, over partnership arrangements, the choice of incentives and over deployment of any additional resources. For primary care trusts (PCTs), certain phases of the commissioning cycle predominated, in particular, purchasing or transactional elements and negotiations with providers of acute health care services. This was, in part, a consequence of supply side dominance, the requirement for PCTs to achieve financial balance and an emphasis on acute sector targets in performance management.

This chapter begins by outlining the history of NHS commissioning in England. This originates in policy decisions of Conservative and Labour governments since the 1990s to separate the task of commissioning services from the responsibility for providing them, as a precondition for policies which promoted patient choice and provider diversity as a route to improved quality and efficiency. It then describes the commissioning cycle as promoted under the world class commissioning (WCC) initiative of the Labour government which in theory, if not always in practice, encouraged a public health-led approach to commissioning.