Editorial Friday 18 July 2014: Commissioning - Schrodinger's Cat bred with the Norwegian Blue

In a time of political choices to give the NHS no more money, commissioning has become the Schrodinger's Cat of the NHS: simultaneously dead and alive.

Commissioning is basically two things: planning and reviewing the quantity and quality of services, and buying them (or not).

The planning and reviewing function is the alive bit. The buying ... you can work it out; you're smart people.

The dead hand of finance
Why is buying dead?

Monitor has done most of it for the system, by setting the national tariff.

Sure, CCGs can piss about at the margins, asking community and mental health providers to take 6-8% cuts on their block contracts (hey, what could possibly go wrong?), but tariff's the big dog with teeth.

CCGs could pay more than tariff, but they don't have the money. Hell, NHS England only got last year into financial balance by failing CCGs on payment-triggering quality links.

CCGs could commission more community provision from their member practices (among others), but they don't have the money.

Tariff looks set to pass the deficit parcel-bomb to providers. Not quite the point, some might say.

A duty to collaborate
Foundation Trusts were given a duty to collaborate with the rest of the NHS by the 2003 legislation that created them. It's not been rescinded.

The cretinous non-anti-competitive clauses of the 2012 Act create issues. Some are existential: the NHS is (in theory, if not always in practice) a collectivist embodiment of planning and collaboration.

Others are political. The NHS has one real ultimate customer, and it's HM Treasury. Until your local CCG or HWB gets tax-raising powers, the buying bit of commissioning is a Norwegian Blue.

A quick economics bit: rising demand + reducing supply + enforcing higher staffing costs = a bankrupt NHS. Which the voting public will notice. And not like.

If political leaders don't choose to resource rising demand, their only hope of avoiding blowing up the money or the quality (or both) is to abandon the purchaser-provider split as currently constituted, and give health economies a budget and governance and responsibility - and let them get on with it.