Challenges of commissioning and contracting for integrated care in the National Health Service (NHS) in England

For many years there has been a separation between purchasing and provision of services in the English National Health Service (NHS). Many studies report that this commissioning function has been weak: purchasers have had little impact or power in negotiations with large acute providers, and have had limited strategic control over the delivery of care. Nevertheless, commissioning has become increasingly embedded in the NHS structure since the arrival of Clinical Commissioning Groups (CCGs) in 2012. Recently, some of these CCGs have focused on how they can contract and commission in different ways to stimulate greater collaboration across providers. This paper examines experiences of commissioning and contracting for integrated care in the English NHS, based on a series of national-level interviews and case studies of five health economies that are implementing novel contracting models. The cases illustrated here demonstrate early experiments to drive innovation through contracting in the NHS that have largely relied on the vision of individual teams or leaders, in combination with external legal, procurement and actuarial support. It is unlikely that this approach will be sustainable or replicable across the country or internationally, despite the best intentions of commissioners. Designing and operating novel contractual approaches will require considerable determination, alongside advanced skills in procurement, contract management and commissioning. The cost of developing new contractual approaches is high, and as the process is difficult and resource-intensive, it is likely that dedicated teams or programs will be required to drive significant improvement.