While commissioning is a relatively new concept, there has always needed to be some infrastructure in place for funding and/or providing services. An issue which is discussed frequently is the distinction between the arrangements for purchasing social care services (through local authorities) versus the process for commissioning health care (through the NHS).
Local government played a slowly increasing role in the development of health and healthcare over the 19th and 20th centuries. The Local Government Act (1929) brought Poor Law infirmaries and fever hospitals into line with other municipal services, without the stigma of the Poor Laws. Before the inception of the NHS as a nationalised service, it was expected that local government would continue to play an expanded role in administering and providing the health service. The 1944 NHS white paper suggested that responsibility for the administration of hospitals would rest with local government, which would set up joint authorities between counties and county boroughs, many of which were too small to provide hospital services individually. It was thought that voluntary hospitals would remain independent, being paid for their services by the joint authorities in a system where there would be a split between some providers of care and the purchasers. The later decision to nationalise hospitals as part of the creation of the NHS marked the start of a perennial debate over the boundaries between NHS organisations and local authorities as well as creating a large monopoly provider.
The NHS was based on a tripartite system when it was established. Hospital services were organised through 14 regional hospital boards across England and Wales, general practitioners were independently contracted to provide primary care services, and local authorities were denuded of responsibility for hospital services while retaining responsibility for community services such as public health functions and community nursing services, which fitted well with responsibilities such as housing and social services.
The NHS reorganisation of 1973 followed the Seebohm report on local government and conflicting proposals over the relationship between health and local government services, and the appropriateness of varying patterns of organisational hierarchy. There was a compromise on the responsibilities of the NHS and local government and the tripartite structure of the NHS was abolished, and the teaching hospital was brought into the same organisational hierarchy for the first time.