Going Private in the Public Sector: Understanding Commissioning Decisions in the English NHS

One popular approach to understanding decision-making in healthcare organisations is the internal/external pressure framework (Pettigrew et al., 1992). It draws on political science and sociology and is favoured as it attempts to take on board national policy directives at the system level and their interaction with more local organisational and professional interests in shaping decision making. The value of this framework was examined in a study which explored the implementation of new commissioning arrangements under the Health and Social Care Act (2012) in the English NHS. This paper specifically examines what influences the decisions of commissioners in the selection of providers and whether they choose public or private providers.

This paper presents findings from a comparative ethnography, which followed the commissioning processes in two CCGs. This ethnography involved interviews with key informants and observation of committee meetings at both CCGs. Throughout, separate specific services, with different histories of private provider involvement, have been traced and examined. Findings suggest that commissioners have much less autonomy to select providers than initially expected which is explained, primarily, by the influence of individual financial situations at each site. Evidence of privatisation is limited in the NHS, with commissioners generally opting for public providers. However, there appears to be an increase in how marketised the service has become, with commissioners making extensive use of market mechanisms to select providers, which resulted from new rules set out by the Health and Social Care Act (2012). The explanatory power of the internal/external pressure framework will be assessed in light of this evidence, concluding with a discussion of the policy implications of this research consisting of how commissioning may change in the next few years and providing a suggested agenda for future research.