Withdrawing funding for hosptials’ mistakes probably won’t lead to better patient care

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If you get an infection in hospital, they’ll receive less funding for your care under a new plan. Presidencia de la República Mexicana/Flickr, CC BY-SA

Helen Dickinson, UNSW

Update: I also did a radio interview with 2SER on this article and the podcast can be found here

The Commonwealth government has just announced a change in the way they fund hospitals, effectively withholding part payment where patients have avoidable complications. The initiative aims to improve the quality of hospital care and reduce overall costs, but without other measures, this probably won’t do much to stop hospital-acquired complications from occurring.

The new plan for hospital funding

Public hospitals are funded by an activity-based system in which they receive money for the services they deliver. Diagnosis-related groups are used to classify hospital episodes of care into a number of codes, which are then reimbursed at amounts set by the Independent Hospital Pricing Authority.

Complications that occur during hospital care, and where there is good evidence these could have been reduced through clinical risk mitigation strategies, are known as hospital-acquired complications. These include things like surgical complications, pressure injuries, falls and health care associated infections.

If you experience a hospital acquired complication then the complexity of your care is likely to increase and you may stay in hospital for longer. This means the cost of care for this treatment goes up. Estimates suggest where you have a health care associated infection the cost of your care increases by 9%, renal (kidney) failure by 21% and malnutrition by 7%.

Pricing Framework for Australian Public Hospital Services 2018-19

From July next year, if you experience a hospital-acquired complication, the hospital will get a reduced rate of funding for that care. Of course, the chance of you developing a hospital-acquired complication will depend on a number of characteristics (such as age and the reason you’re in hospital), and not just the quality of care you receive.

So the amount of money the hospital loses is determined using a risk adjustment model. Assessment against a range of characteristics determines whether an episode of patient care is low, medium or high in terms of complexity, and this score is used to determine the funding reduction.

If a patient is at low risk and experiences a hospital-acquired complication, the hospital will receive funding for that person’s care reduced by the full incremental cost of the hospital-acquired complication. If a patient is at high risk then the funding for that episode of care will be reduced by a proportion of the incremental cost of the hospital-acquired complication. The new policy builds on a change to funding systems that was introduced in July, which withdrew funding for serious errors (so-called “sentinel events”).

Read more: Punishing medical errors won’t improve hospital safety or quality

Why this approach is being introduced

It’s estimated that for the years 2014-15 and 2015-16, there were just over 101,000 and over 104,000 cases in Australian hospitals of hospital-acquired complications, respectively. So the money spent on these cases could have been put to other uses across the health system. The Independent Hospital Pricing Authority estimates A$280 million will be saved by introducing this policy.

The idea is this scheme will mean hospital managers and staff work harder to ensure they avoid these issues occurring. The scheme is not designed to eliminate hospital-acquired complications entirely – this would be very difficult to achieve in a complex system like a hospital.

But the intention is the threat of losing some funding should drive processes of improvement. The resulting impact for those receiving hospital care can be significant if it means you avoid a significant or traumatic complication that compromises your health.

What could be some of the negative impacts of the approach?

The challenge with this type of approach is we don’t know whether pay for performance works. It’s widely debated, but on the whole hasn’t achieved the expected gains in health effectiveness and safety.


Exciting news about JHOM

I am lucky enough to have a couple of editorial roles with journals, one with the Journal of Health Organisation and Management (JHOM) and the other with the Australian Journal of Public Administration (AJPA).

We recently got the very exciting news that JHOM has been accepted into the Social Sciences Citation Index and will get an impact factor.  This is exciting news as having an impact factor is one of the ways that academics (and research excellence exercises) determine the relative merit of publications.  JHOM was submitted for review about four years ago now so it has been a long journey and we are really happy with the outcome.

The press release can be found below and if you are interested in submitting a piece to JHOM then I am happy for you to get in touch with me directly.

Press release

As contributor to Journal of Health Organization and Management (JHOM), we are delighted to let you know that the journal has been accepted into Clarivate Analytics (formerly Thomson Reuters) Social Sciences Citation index (SSCI). This decision reflects the increasing quality and impact of the journal and the dedication of the editorial team, led by co-editors Helen Dickinson, University of New South Wales, Australia, and Suzanne Robinson, Curtin University, Australia.


SSCI is a key database within Clarivate Analytics Web of Science™ Core Collection and covers content in the social sciences discipline. Inclusion in the SSCI means that the Journal will receive an impact factor, the first one will released in Summer 2017.


To celebrate this exciting news, the latest issue of JHOM (Vol 31 issue 2) will be available on free access from 19th May- 18th June 2017. Please follow this link to the free access: http://bit.ly/2qw2hHZ


The editors are currently welcoming submissions to the journal. Inclusion in SSCI will provide greater discoverability for authors published, so now is an ideal time to submit your work. To submit to the journal, please use the online submission system: http://mc.manuscriptcentral.com/JHOM.


For queries, please contact the Editors, Helen Dickinson, h.dickinson@adfa.edu.au, Suzanne Robinson,  suzanne.robinson@curtin.edu.au, or the Publisher, Wendy Alderton, walderton@emeraldgroup.com.


Feel free to forward this exciting news to your peers and colleagues.


Finally, I would like to take this opportunity to thank you very much for your valuable contribution to the quality of the journal and your continuous support.


With very best wishes,


Emma Leverton





Emma Leverton, MA

Publishing Editor | Health and Social Care | Emerald Publishing

Tel: +44 (0) 1274 785157

eleverton@emeraldgroup.com | www.emeraldpublishing.com | www.emeraldinsight.com   


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Budget 2017 sees Medicare rebate freeze slowly lifted and more funding for the NDIS: experts respond

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The future of the NDIS is seemingly secured in this federal budget.
from shutterstock.com

Stephen Duckett, Grattan Institute; Chris Del Mar; Elizabeth Savage, University of Technology Sydney; Helen Dickinson, UNSW, and Michael Woods, University of Technology Sydney

As expected, the government has announced a progressive lifting of the Medicare rebate freeze. Together with removing the bulk-billing incentive for diagnostic imaging and pathology services, as well as an increase in the PBS co-payment and related changes, this will cost a total of A$2.2 billion over the forward estimates.

Other announcements include:

  • From July 1, 2019, an increase in the Medicare levy from 2% to 2.5% of taxable income, with the extra half a percent directed towards the NDIS
  • $1.2 billion for new and amended listings on the PBS, including more than $510 million for a new medicine for patients with chronic heart failure
  • a A$2.8 billion increase in hospitals funding over forward estimates
  • $115 million for mental health, including funding for rural tele-health psychological services, mental health research and suicide prevention
  • $1.4 billion for health research, including $65.9 million this year to help research into children’s cancer.

All up, these commitments equate to A$10 billion.

Medicare rebate freeze

Stephen Duckett, Health Program Director, Grattan Institute

As foreshadowed in pre-budget leaks, the government is slowly unthawing the Medicare rebate freeze, but at a snail’s pace. At a cost of A$1 billion over the forward estimates, indexation for Medicare items will be introduced in four stages, starting with bulk-billing incentives from July 1, 2017.

General practitioners and specialists will wait another year – until July 1, 2018 – for indexation to start up again for consultations, which make up the vast bulk of general practice revenue. Indexation for specialist and allied health consultations is slated to start from July 1, 2019.

Certain diagnostic imaging items (such as x-rays) will be the last cab off the rank. Indexation will start up again from July 1, 2020.

There is no mention of reintroducing indexation for pathology items. This may be due to the recognition that there is money to be saved in pathology.

Regardless of the reaction of medical lobby groups, it is too early to tell whether this glacially slow reintroduction of indexation will be enough to keep bulk-billing rates at their current levels. Practice costs and income expectations of staff have not increased dramatically over the freeze period as the Consumer Price Index has been moving slowly. But each additional day of a freeze means costs and revenues fall further out of alignment.

The jury will be out for a while on whether reintroduction of indexation is enough to restore the Coalition’s tarnished Medicare credentials with voters.

Certainly, the slow phase-in may attract cynicism, with a legitimate perception the government is doing the minimum necessary and at the slowest pace to ensure the issue is off the agenda before a 2019 election.

There is no sign in the budget that the government has sought any trade-offs from the medical profession in exchange for the reintroduction of indexation, so we will have to wait to put in place better foundations for primary care reform.

National Disability Insurance Scheme (NDIS)

Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

Since its inception, a number of bitter political battles have been fought over how the National Disability Insurance Scheme should be funded. Many have been nervous the current Productivity Commission review of the costs of the scheme could lead to a scaling back of the NDIS before it is fully operational.

The NDIS operates under a complex funding arrangement split between federal, state and territory governments. Until now it has been unclear where the federal component of this commitment will come from, and a significant gap was emerging from the middle of 2019.

Today’s budget promises to fill this funding gap, in part through an increase by half a percentage point in the Medicare levy from 2% to 2.5% of taxable income. Of the revenue raised, one-fifth will be directed into the NDIS Savings Fund (a special account that will ensure federal cost commitments are met).

A commitment has also been made to provide funding to establish an independent NDIS quality and safeguards commission to oversee the delivery of quality and safe services for all NDIS participants.

This will have three core functions: regulation and registration of providers; complaints handling; and reviewing and reporting on restrictive practices. While such an agency will be welcomed by many, the devil will be in the detail as to whether it is possible to deliver this in practice.

Generic Medicines

Chris Del Mar, Professor of Public Health, Bond University

The government is set to save A$1.8 billion over five years by extending or increasing the price reduction for medicines listed on the Pharmaceutical Benefits Scheme (PBS).

This will be achieved in part by encouraging doctors to prescribe generic medicines that name the active ingredient (as in “90 octane petrol”) rather than the brand name (as in “BP” or “Shell”). This has the effect of pharmaceutical companies selling the drug that is cheapest.

It doesn’t work for drugs still under patent (which allows only pharmaceutical companies holding the patent to negotiate a price, compensating them for the drug development costs). But when drugs come off patent, any other pharmaceutical company can manufacture the generic drug for the best price.

Some doctors worry different brands might have different effects, but there are very few examples of patients being harmed by this. Australia’s Therapeutic Drugs Administration (TGA) makes sure drugs are manufactured to tight standards.

However, many patients know their medications by the brand name rather than the generic name. This same problem can happen right now (when patients are prescribed the same drug with two or more different names when they are prescribed by GPs, hospitals, or specialists).

Doctors are already alert to ensuring that different drugs names do not confuse patients – the danger is that they take the same drug twice, thinking they are different drugs.

Aged care

Michael Woods, Professor of Health Economics, University of Technology Sydney

The government has held the line on restraining growth in funding to residential aged care providers in this budget by implementing its pre-announced indexation freeze for the year, and a partial freeze in 2018-19.

The freeze was in response to concerns some providers were wrongly over-claiming payments under the Aged Care Funding Instrument (ACFI). The instrument determines the level of funding the government pays to providers to care for their residents.

The government has stopped publishing its annual target number of ACFI audits, so any proposed changes in compliance activity are now unknown.

The long-awaited consolidation of the Home Care Packages (which aim to help ageing Australians remain at home for as long as they need) and entry-level support through the Commonwealth Home Support Program has been put off for another two years, until at least 2020-21. This will be disappointing to consumers as a more seamless set of support services will improve their ability to remain in the community.

A welcome initiative is the additional A$8.3 million for more home-based palliative care services, although this extra support is budgeted to end in 2019-20.

Overall, the biggest unanswered issue facing the government in aged care is the need to develop an evidence-based and sustainable funding regime for residential care. To date we have seen short-term budget fixes and the commissioning of opaque rushed research reports.

The health minister needs to step back and establish a proper policy review process that undertakes sound research and consults widely. The review needs to establish a set of core funding principles and model options that address the varying incentives of residents, providers and taxpayers. It needs to adopt the one that transparently empowers consumers, provides market competition and results in long-term sustainability and certainty.

An inequitable budget

Elizabeth Savage, Professor of Health Economics, University of Technology Sydney

The budget has increased the Medicare levy (from 2.0% to 2.5%). It also has removed of the 2% budget repair levy, which benefits individuals with taxable incomes above A$180,000.

In 2014-15, only 3% of taxpayers had taxable incomes above $180,000. By contrast, the Medicare levy increase affects almost all taxpayers. This is a tax increase designed to generate revenue to fund the NDIS. The Medicare levy is essentially a flat tax, except for those at the lowest end of the distribution of taxable income.

Revenue could have been raised more equitably by increasing marginal income tax rates for higher earners (including making the budget repair levy permanent) or lowering upper tax thresholds.

What’s missing from the budget?

The 30% subsidy for private health insurance was introduced in 1999, and cost the budget A$2.1 billion in 2000-01. This cost has grown steadily and was estimated in the 2016-17 budget to be about A$7 billion for 2017-18. Despite high population coverage, consumers question whether private health insurance provides value for money.

There is abundant evidence the subsidy is an ineffective and costly policy, but it seems the politics keep reform of the subsidy in the too-hard basket.

From the budget speech and budget papers, it is not clear that there is any reform of the pricing of prostheses for private hospital patients. The Prostheses Listing Authority, the government regulator, sets minimum benefits for prostheses for private hospital inpatients.

The levels set are far higher than both prices in comparable overseas countries and those paid by public sector hospitals in Australia. Private hospitals are major beneficiaries when the regulated minimum benefits exceed the negotiated prices paid to suppliers.

Private health insurance premium increases are being driven by hospital benefits, of which 14.4% are for prostheses. In 2015, insurers paid out almost A$2 billion in hospital benefits for prostheses.

The previous health minister, Sussan Ley, raised prostheses reform as a priority, noting that insurers pay $26,000 more for a specific pacemaker for a private patient than a public patient ($43,000 compared with $17,000). It appears from early documentation that this problem has not been prioritised in this budget.

Stephen Duckett, Director, Health Program, Grattan Institute; Chris Del Mar, Professor of Public Health; Elizabeth Savage, Professor of Health Economics, University of Technology Sydney; Helen Dickinson, Associate Professor, Public Service Research Group, UNSW, and Michael Woods, Professor of Health Economics, University of Technology Sydney

This article was originally published on The Conversation. Read the original article.

Labor’s Health Policy Summit

A few weeks ago I was one of a number of people invited to attend the Labor National Health Summit.  This event was held to help shape Labor’s health policy agenda heading into the next Federal election.

With colleagues from the Centre of Research Excellence in Health and Disability, I wrote some reflections on the event and what the discussions mean particularly for people with Disability for the good people over at Croakey.  You can find out our take on this here.


What next for health?

This weekend marked my second Australian general election and turned out to be a pretty eventful one.  Here’s what I had to say about the implications of the results for health policy, which was published on the University of Melbourne’s Pursuit site.

In the run up to the election, health policy was a key point of debate. A number of commentators have already suggested that Labor’s accusations that Coalition plans to privatise Medicare may have been instrumental in significant gains for Labor, particularly in Tasmania. Meanwhile, the Prime Minister has announced that the Federal Police will investigate text messages sent by Queensland Labor urging voters not to back the Prime Minister and his government in order to “save Medicare”.

Regardless, of what plays out as a government is formed, what is clear is that health will remain a hotly contested issue. With the political move to the centre in recent years it has been difficult to distinguish between traditional party positions. To some degree Labor have attempted to return to days gone by in presenting themselves as the saviours of Medicare.

Yet the outcome of this process is likely that there will be little hope for significant reform of the health system. This outcome will not leave any government with a clear mandate or render them willing to take on a substantial health reform process. Indeed, parties may feel that the greatest reward comes not through a positive vision for the future, but through scare campaigns and negativity. None of which offers much hope for substantive change.

In the run up to the election there was not much to divide the various promises of the parties on the health front. Both argued that they were committed to maintaining universal health services. Labor planning to do this through a cash injection into the system and by making savings on private health insurance. The Coalition committed to more limited investments, but with a desire to use existing resources more effectively (including those in the private health system). But what was missing in these election commitments was a clear sense of how the health system would be reformed in a significant way to ensure that we see the level of change that is needed to ensure that this performs as well in the future as it does now.

This election has demonstrated that people care deeply about their health system, but this will not result in politicians feeling courageous about taking on reform in a significant way. The fractured parliament that we will inevitably be left with will also make it more difficult than ever to pass legislation. No doubt we will see money freed up for various different agendas – and likely many of these will focus on interests of independents holding the balance of power. But none of this bodes well for those of us who wish to see Australia embark on a careful and considered reform of its health system.

Explaining Primary Health Networks and commissioning

As Primary Health Networks approach their first anniversary a number of people have asked what kind of progress they have made to date and what’s to come over the next 12 months or so as they roll out their first commissioning strategies.

The Health Services Research Association of Australia and New Zealand recently hosted a webinar ably chaired by Associate Professor Suzanne Robinson (Curtin University, WA) and comprising a panel of me, Learne Durrington (Chief Executive, WA Primary Health Alliance) and Jason Trethowan (Chief Executive Officer, Western Victoria Primary Health Network Ltd.) to review the progress of PHNs to date.

The background to the webinar can be found below and if you want to view the discussion then you can find this here (due to some odd technical issue I am missing for the first 10 minutes or so!).

Health systems are challenged by pressures of increased demand and rising costs. The rise in complex chronic conditions means that the current system design that stems from an era when communicable disease was more prevalent than chronic is struggling to meet the changing health needs of the population. As governments look to ways to reform health systems we have seen an interest in the role of commissioning as a mechanism through which to reform many different aspects of public services. Primary Health Networks (PHNs) have been charged with commissioning primary care services in Australia. The essence of commissioning is to take a stewardship role with a focus on providing vision and direction for the health system, collecting and using intelligence, and exerting influence – through regulation and other means.

As PHNs reach their first birthday it’s timely to take stock of how commissioning is developing both nationally and internationally. The webinar incorporated research, policy and practice perspectives on the development and implementation of commissioning in Australia.

The panel session focused on broad areas relating to the following:

  • The current understanding of commissioning, and what it should achieve in PHN  localities;
  • The challenges and opportunities of the commissioning process in Australia;
  • Concepts and elements of successful commissioning;
  • How are PHN commissioners working with wider stakeholder groups?

Better partnership working

At the end of last year I was pretty hard at work revising a book series that I was first involved in back in 2008.  At this time I was a series editor and autho

r or co-author on a number of books all broadly related to collaborative working.  These were published by Policy Press and aimed to be short, academically robust, but accessible books for health and social care professionals and students with an interest in partnership working.

Not only was there a learning curve because these were the first books I had ever written, but it also turns out that writing five books at the same time with different co-authors within the space of about 8 months and doing a full time job and a PhD is pretty tricky.  Who would have thought?  Had you told me then that 7 years on I’d go through the same process I would have been pretty surprised (although at least now I have finished my Phd so have less of a workload!).  And yet that is precisely what has happened and mostly because of the reaction of health and social care professionals to the collection.

Writing academic books is often a fairly solitary experience and publishing doesn’t always feel like the ‘big bang’ change that some people often assume that it will be.  I don’t think it is unfair to say that often books can largely go unnoticed by all but a small and specialist community (well until a family member stumbles across you on Amazon and gets a surprise).

What was interesting about this series is that when meeting health and social care professionals in various parts of the UK people would know the books and often had one or more of the set and actually used it in the course of their work.  When going to people’s offices it wasn’t unusual for someone to fish a dog-eared copy out of a desk draw as they spoke about how they had drawn on the various frameworks and tools within.  The books seemed to be genuinely useful to people grappling with the complexities of making collaboration work on a day-to-day basis.  I don’t think this could be a greater compliment given what we set out to achieve.

The series sold fairly well and Policy Press had positive feedback and commissioned us to revise the first book in the series in 2014.  We did this and again it was met with a strong response and a request for the others to revisited and updated.  So in early 2015 I found myself agreeing to revise the remaining four  books in the series and deliver them in a space of about 7 months.

On coming back to the books we realised how much the evidence base and the policy context had moved on – even though many of the same questions remain unanswered fully.  There were also a number of things we were keen to improve on and change – such as a desire to inject a more international flavour into the books.  Given issues over availability of some co-authors and work I’ve done with others of late there have also been some author line-up changes in some places.

The revision of the books actually became less of an update and more of a re-write and most are substantially different as a result.  This made the whole process even more of a challenge again but I think we are pretty happy with the end result and hope that this continues to make the books as relevant today as they proved to be when the first editions were published.

The revised series is available now as a set of books or as individual publications.  The series starts with an introductory book written with Jon Glasby called Partnership Working in Health and Social Care, which provides an introduction to the topic area, an overview of the (mostly) UK policy context and evidence about what makes collaboration work.  Having set out the background the remainder of the books in the series focus on different themes in relation to health and social care collaboration.

With Gemma Carey the focus is on Managing and Leading in Inter-agency Settings, providing an overview of the literature around some of the most talked about critical factors in making collaboration work.  Working in Teams is theme for the book with Robin Miller and Kim Jelphs.  Or I should more accurately say Dr. Robin Miller as he recently successfully defended his PhD thesis.  Dr. Miller recently wrote this blog post on the content of the book.

With Janine O’Flynn the focus is on Evaluating Outcomes in Health and Social Care, focusing on the evidence for collaboration and detail about how to go about assessing the impact and benefit of joint working.  Last but not least is Interprofessional Education and Training with John Carpenter, providing a summary of the key components of the IPE literature and how this supports joint working.

All in all these were a great team to work with as were Policy Press.  I am looking forward to seeing the final books in print (once they finally make it through the Australian postal system) and hope that they prove as useful as the first editions.  Although if we are to be luck enough to be asked for a third edition I hope someone reminds me of this blog post…

On commissioning and the Emperor’s new clothes

If you have seen me present on commissioning in the last few months then chances are you will have heard me talk about some of the current debates about this remind me of Hans Christian Andersen’s story the Emperor’s new clothes.

Now this might not seem like the most robust academic analogy but I think it is a helpful one because it is probably something that most people are familiar with or can get to grips with pretty quickly.  It’s a familiar tale and allows us to populate it with the various characters and use it to make sense of difficult and complex situations.   This tale in particular is often still invoked as an idiom or a cautionary story.

Before I start to relate this to the concept of commissioning I will do a brief re-cap of the story as I realise not everyone had the pleasure of reading these tales as a child (or continue do so as an adult like I do).  For those of you who want to skip my patchy description there are some cracking clips on YouTube that do far more justice than I will – like this.


The plot in this story revolves around a vain Emperor who loves wearing the best clothes.  Two weavers come to town and promise him the finest suit of clothes from a fabric invisible to anyone who is unfit for his position, or who is, in the words of the time pre-political correctness, ‘hopelessly stupid’.  The Emperor’s ministers can’t see the clothes but pretend to as they don’t want to fear being unfit for their roles and the Emperor does the same. The story culminates in the Emperor marching through the town in his new suit and the townsfolk playing along with the pretence, not wanting to appear unfit or stupid.

A child in the crowd who is too young to understand the need to keep up the pretence shouts out ‘he’s naked’ and the other townsfolk join in at this point having been freed from this social bond. The story finishes with the Emperor suspecting that he is naked but not wanting to admit it still.

The beauty of this short children’s tale is the wide array of different allegories that it contains.  I don’t invoke this tale as a perceived attack on the pride or vanity of policy makers (heaven forbid) or event to suggest that they surround themselves with individuals of an obsequious nature. It is not, either, an argument for children to run public services as the only group able to spot untruths or nonsense. One need only watch a small amount of the Wiggles to know this not to be the case.  Neither is this to suggest that the commissioning agenda – like the Emperor’s new clothes – is little more than a collective belief in nothing.

Why I use this metaphor is to guard against the unquestioning acceptance of ideas or the uncritical appraisal of solutions. In a context where many are desperately seeking for solutions that will help to transform public service systems, the temptation can be to  jump to embrace the next idea that promises to help us overcome the myriad of challenges that we face. As this story tells us, what sounds like a perfect answer rarely is in practice if we simply accept it in an uncritical way.


Commissioning as a term developed initially in the UK as a response to attempt to create more effective stewardship of what had increasingly become very complex service delivery environments and where government agencies lacked traditional means of control over the various organisations within this context.  Commissioning in a dictionary definition sense covers a range of different stewardship functions including those relating to funding, ownership, purchasing, provision and regulation. The breadth of this definition is important because commissioning is more than simply outsourcing more functions or a way of externalizing aspects of provision. It is about systematically steering complex public service systems (and I’ve written more about the background to commissioning in previous posts).  The key point is that commissioning is a complex set of functions than involve technical and value-based decisions, such as concerns over ethics, equity and values.

The magnitude of the challenge of commissioning is illustrated in relation to the range of drivers that underpin this agenda. Commissioning is about efficiencies – both technical (in terms of provider performance) and allocative (across the whole budget), but is also about response to consumers, making priority decisions more explicit, challenging a range of traditional approaches to resource allocation and the dominance of some sectional interests and a counterweight to professional dominance in processes of service specification.

Yet, when we turn to the evidence concerning commissioning and impact, overall we find that there is a lack of evidence to demonstrate that across-the-board commissioning approaches positively impact efficiency, quality of services or outcomes of services. Although there is some evidence of impact in terms of efficiency, services responsiveness and quality, on the whole these tend to be rather isolated incidences.  In some cases the introduction of commissioning approaches has led to other inefficiencies in terms of managerialism, datamania and other disruptions.

It is important to note that commissioning is difficult to measure and to talk about with any certainty.  One experience familiar to those who have attempted to explore the outcomes of commissioning is that where a positive impact is identified there can be protracted debate between commissioners and providers about who it was that had the greatest impact on these outcomes!



Despite the lack of evidence, the call for commissioning continues.  We have seen this recently in Australia in terms of the central role that this plays in Primary Health Networks and the creation of Commissioning and Contestability units in some State Government departments.  It looks like this agenda still has some way to run.  Yet, the gap between evidence and action has led some to question whether this latest wave of reform will deliver real change or just involve lots of talk about something new and different but nothing new in reality?

Juliet Woodin and Judith Smith make an important observation relating to the notion of expectations. They point out that commissioning was introduced in the UK against a background of high expectations (as we have seen in the range of drivers that it is supposed to achieve) and at a time of significant social and economic challenge – not to mention the fact that the commissioning architecture has undergone significant and sustained reform over the years.  Furthermore, there have not been significant investments in evaluating the impact of commissioning approaches. This means we cannot say for certainty whether or not commissioning has significant impacts particularly over the long term.

Why these are observations are helpful is they remind us that the function of commissioning is a complex one being realised against a backdrop of significant turbulence and disruption. We therefore need to realistic about what we might expect to see in terms of impact and over what kind of timescales. It is unrealistic to expect that commissioning can deliver against all the outcomes that have been promised of it overnight and it will need the courage to stick with an agenda but also the astuteness to identify when things are going awry if it is to be successful.

At the moment I seem to spend a lot of time talking with public servants up and down the country about commissioning and it is safe to say that many are sceptical about this agenda and whether it is underpinned by any significant substance.  It is true that we could look at this agenda in a rather sceptical way and it see it as just the next big political whim with unclear parameters and a shaky evidence base.  Indeed if we do see it like this then there is a strong chance that the Emperor will stay unclothed.  But, to stretch the analogy to breaking point, I think there is more we could with this concept to ensure that the Emperor is dressed.  In my next blog post I’ll set out what some of these steps are.