College of Medicine, Swansea University SA2 8PP, UK.
BMC Health Serv Res. 2013;13 Suppl 1(Suppl 1):S2. doi: 10.1186/1472-6963-13-S1-S2. Epub 2013 May 24.
Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.
We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.
In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.
Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.
自 1991 年以来，英国国民医疗服务体系（NHS）进行了一系列改革，服务的管理者与能够竞争 NHS 患者服务合同的公共和独立部门供应商之间的分离程度不断加深。我们考察了在最新一轮市场化改革进行数年之后，地方管理者在多大程度上采用了面向市场（交易型）的长期病患者护理委托模式。本文还考虑了可能抑制或支持面向市场行为的因素，包括有利于医疗保健准市场存在的条件。
我们在两年时间里（2010-12 年）研究了英格兰三个基层医疗信托（PCT）地区三种长期病患者（糖尿病、中风和痴呆）的服务委托情况。我们广泛采用人种学方法来理解委托实践的日常运作。数据通过访谈、会议观察和文件收集。
与以管理者选择供应商和相关合同为核心的交易型、与市场相关的方法相反，委托主要是关系型的，基于与现有供应商的信任和合作。管理者没有明显迹象表明在重大挑战供应商、更换供应商或取消服务。在所有服务领域，医疗保健中准市场良好运作的所有条件都不存在或有限。供应商选择通常不存在或有限；关于需求和资源需求的信息极不完善；动机复杂；交易成本不确定，但可能很高。很难将护理分割成用于合同目的的整洁单元。因此，毫不奇怪，在与所有六项委托发展相关的委托实践中，关系型方法占据主导地位。
我们的发现挑战了管理者和供应商严格分离的观点，相反，证明了基于连续性供应、管理者和供应商之间的信任和相互依存的关系型委托的适应性持续存在，至少对于长期病患者服务而言是如此。
