How managed a market? Modes of commissioning in England and Germany.

Rod Sheaff, Naomi Chambers, Nigel Charles, Mark Exworthy, Ann Mahon, Sue Llewelyn, Richard Byng, Russell Mannion

Research output: Contribution to journalArticlepeer-review


a. Background
In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control (' media of power ') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so.
b. Methods
Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources.
c. Results
The comparison exposes and contrasts two basic generic modes of commissioning:
1. Surrogate planning (English NHS), in which a negotiated order involving
micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers.
2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power.
d. Conclusions
Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control.
Original languageEnglish
JournalBMC Health Services Research
Issue numberS1
Publication statusPublished - 2013

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