Commissioning and contracting (also sometimes described as purchasing or procurement) are complex and much debated features of many healthcare systems today. This chapter initially explores commissioning and contracting through an account of the healthcare policy context within which they have developed, as a backcloth to understanding how the terms are commonly defined and understood. The key elements of commissioning and contracting will then be described, and the technical difficulties of implementing such systems in healthcare discussed. The chapter then considers how commissioning is organised to deliver this complex role. Finally, the chapter examines the evidence about the effectiveness and impact of commissioning in achieving health system goals.
Organised healthcare systems are complex entities and include a number of fundamental functions and roles, which are shown in Box 12.1. In insurance-based systems, such as the United States of America (USA), Germany and the Netherlands, the insurance organisation (third party payer) is usually separate from the provider of services (although there are also examples of integration in the USA (Enthoven 1994). In tax funded, publicly run systems such as the United Kingdom, Sweden and New Zealand, third party payers and service providers have traditionally been largely within the same organisation.
During the last decades of the twentieth century healthcare reforms took place in many developed healthcare systems, which made changes to the third party payer role and its relationship with the provider role. These trends during the 1970s to 1990s can be seen as consisting of two phases: during the late 1970s and early 1980s a focus on cost containment