The House of Commons Health Committee’s 2010 report was published as a result of the committee’s decision to undertake an in-depth investigation into commissioning, prompted by concerns raised over the system’s ability to effectively commission services. The report pointed out the high transaction costs of commissioning and noted that:
'There are examples of good work being undertaken by PCTs. However, many PCTs believe they are working effectively although the evidence would suggest otherwise. As the government recognises, weaknesses remain 20 years after the introduction of the purchaser–provider split... Weaknesses are due in large part to PCTs' lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management. The situation has been made worse by the constant reorganisations and high turnover of staff. We have had the disadvantages of an adversarial system without as yet seeing many benefits from the purchaser–provider split. If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser–provider split may need to be abolished.'
The committee concluded the following:
Quality of commissioning
- The implementation of the Carter Review had led to improvements in specialised commissioning, but greater progress was still needed and issues such as local variations needed to be addressed.
- The committee felt that from the evidence it received, PCTs appeared disengaged from specialised commissioning and gave it a low priority. There were concerns that, as a result, PCT budgets for this area would be reduced due to underuse. It was recommended that the Department of Health should conduct a review of the issues on specialised commissioning.
- Weaknesses in commissioning were a legacy from the introduction of the purchaser–provider split in 1991.
Skills of commissioners
- Commissioners were passive and did not consistently and robustly challenge providers on quality and in efficiency. The committee noted a deficiency in commissioning skills (eg data analysts and clinical knowledge), which was made worse by frequent reorganisations and high staff turnover.
- Commissioners lacked adequate levers to challenge and stimulate providers.
World class commissioning
- The committee was critical of world class commissioning (WCC), branding it as ‘ridiculous’ and ‘unexceptional’, and noted concerns about the capability of PCTs to make the significant changes required by WCC.
- WCC was unlikely to address the skills gaps in commissioning. The committee highlighted the risk that WCC could become a ‘box-ticking exercise’ rather than a genuine opportunity to support capability improvement. The committee recommended that the Care Quality Commission used the 11 competencies of WWC to judge PCTs.
- The committee raised concerns over the government’s application of initiatives such as patient reported outcome measures (PROMs), the commissioning for quality and innovation (CQUIN) framework, quality accounts and never events, without piloting and evaluating them.
The purchaser–provider split
- The purchaser–provider split had led to an increase in management and administration costs.
- It was felt that if reliable data showed the costs of the purchaser–provider split was uneconomical, then the government should consider abolishing it as a ‘costly failure’.
The future of commissioning structures
- Strategic health authorities should be subject to cuts to achieve savings. It felt that if PCTs were to be retained they needed to be strengthened with a more skilled workforce, capable of effective commissioning. PCTs also needed to be equipped with better levers to negotiate with providers.