Programme approach to managing informed commissioning

The objective of this paper is to examine possible organizational reasons for why UK NHS commissioners have not adopted programme budgeting and marginal analysis (PBMA). This is despite increasing evidence of discontent with current commissioning and priority-setting processes, increasing research evidence demonstrating the potential of PBMA and support for the principles of PBMA. Two separate semistructured surveys of the views of commissioning decision-makers on the use of PBMA were carried out at Grampian Health Board and Newcastle & North Tyneside Health Authority. Twenty-nine decision-makers were interviewed. Both surveys found common barriers to implementation of PBMA, described by respondents as 'institutional inertia'. These were the reactive rather than proactive environment; the fear of 'unnecessary' explicitness; an aversion to unilateral innovation in the current NHS environment; and the demand for concrete evaluation evidence. It is concluded that these qualitative surveys have small samples and cannot claim to be representative. It may be significant that many issues were common to both surveys carried out separately in organizations. It is unlikely that NHS commissioning will independently adopt techniques such as PBMA, given the current commissioning environment and organizational structures. Implementation strategies and future research on such commissioning innovations may need to focus on institutions as well as the interventions.