Key points
- Commissioning is the primary function of primary care trusts (PCTs) in England. PCTs are responsible for just over 80 per cent of the total NHS budget – approximately £85 billion – and commission services from a range of NHS, private and voluntary sector providers.
- The amount allocated to each PCT varies according to a complex ‘weighted capitation’ formula designed to link budgets to local needs (for example, Manchester gets more than twice as much per head of population than Oxford).
- PCTs are expected to work within this cash limit. Recent changes to the budget allocation formula have led to ‘winners’ and ‘losers’, with some PCTs facing potential disruption to services as a result of cutbacks.
- The evolution of commissioning in the NHS began when the ‘internal market’ was introduced in 1991. Two models of purchasing developed: health authorities, centred on the health needs of the population; and fundholding, where GPs in individual practices or consortia could purchase elective care for patients.
- In 1997, GP fundholding and its variants were abolished in favour of primary care groups and trusts (PCGs and PCTs). An extensive period of reform and organisational upheaval, including the phasing out of health authorities in 2002, has led to the current situation where there are 152 PCTs in England.
- In 2005, practice-based commissioning (PBC) encouraged ‘virtual’ budgets to be placed in the hands of GP practices to make commissioning decisions in partnership with PCTs. However, only very modest progress had been achieved to date.
- In 2007, world class commissioning (WCC) was developed as a way of bringing a ‘step change’ in the commissioning capacity and capability of PCTs and practice-based commissioners. The WCC programme has set out a range of core competencies that PCTs need to achieve, alongside an assurance framework that measures, supports and holds PCTs to account.
- In July 2010, the Coalition government’ set a three-year timetable to devolve commissioning budgets to GP consortia and to phase out PCTs. It is planned that these GP consortia will become new statutory organisations led by GPs and other clinicians with all GP practices being mandated to become a member of a local commissioning consortia (see Equity and excellence: Liberating the NHS)
- Following the government’s ‘listening exercise’ that completed in June 2011, the Department of Health shifted their description of the leading local NHS commissioning bodies from ‘GP consortia’ to ‘clinical commissioning groups’ (ccgs). These groups will still be based around GP practices, but clearer assurances have now been made to ensure the wider professional involvement and engagement of doctors (including secondary care clinicians/ specialists), nurses, and other health and care professionals, patients, carers and the public. The governing body of each ccg will have to include at least one registered nurse, and one secondary care specialist doctor.
- Ccgs will ‘have a duty to promote integrated health and social care around the needs of users’ (Department of Health 2011)
- Plans for the authorisation and assessment of ccgs, and the accountabilities between ccgs, the NHS Commissioning Board, and health and wellbeing boards are currently being developed by the department.
- The Department of Health has set out that ‘By April 2013, GP practices will be members of either an authorised clinical commissioning group, or a ‘shadow’ commissioning group, i.e. one that is legally established but operating only in shadow form, with the NHS Commissioning Board commissioning on its behalf’.
