Special issue on commissioning.

Abstract

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 provisionof servicesthrough 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. Inresponse,healthandcommunityservicesorganisations 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 nongovernment 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).