There are two broad models of how a state-funded healthcare system can operate. Either the government gives each section a budget and the different parts of the service manage more or less well within the budget, or one part of the service acts as the taxpayers' agent and buys or commissions services from other parts which compete to offer the best service at lowest cost. This latter model mirrors the commercial world. This purchaser/provider split has been a feature of healthcare policy for nearly three decades. For the system to function, those who purchase or commission the service have to have a set of competences.

World Class Commissioning

The 2007 ‘World Class Commissioning’ programme was an attempt both to define what commissioners have to do and to provide an assessment and national grading of how well they were achieving the task. The framework had a number of elements:

• Local leadership – the commissioners are supposed to be the leaders in the local NHS economy, enjoying a strong reputation with all the public sector organizations as well as the healthcare community

• Partnership working – the health of a community depends on local government, schools, housing policy, jobs, etc., and the commissioners have to work closely with those responsible for all issues which affect the health of a local population

• Engage the public – commissioners are buying on behalf of the public and need the public to buy into any plans

• Engage clinicians – commissioners need to have input from the whole clinical community in developing strategy and services and in ensuring quality

• Knowledge management – commissioning requires a great deal of knowledge in a very broad range of fields. The knowledge needs not only to be current but must anticipate changes in disease patterns and new technological advances. Prioritization decisions have to be evidence-based and there has to be an audit trail so that there can be challenges and appeals

• Needs assessment and prioritization – the commissioners need data and an in-depth understanding of the health needs of the community they serve. This should underpin their decision-making.

• Agents for change – commissioners should not be satisfied with the status quo but should stimulate the healthcare market, challenge existing providers and encourage new providers

• Drive for quality and innovation – the commissioners need to drive for continuous improvement by specifying quality and outcome targets they wish to see achieved on behalf of their population

• Procurement and contracting – commissioners need to be experts in the nationally regulated process of procurement and put in place proper contacts which protect the service and ensure value for money

• System management – commissioners manage the healthcare system and need to ensure via contract and outcome monitoring that the local population receives a sustained high quality service delivered by reliable resilient organizations

• Financial investments – commissioners are responsible for the money spent in the local healthcare economy. This will typically be many hundreds of millions of pounds. They are accountable for ensuring that the service is financially stable and that sound financial investments are made.