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BMC Health Serv Res. 2019 Apr 15;19(1):228. doi: 10.1186/s12913-019-4013-5.

Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link.

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Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK.
Personal Social Services Unit, London School of Economics, Houghton Street, London, WC2A 2AE, UK.
Centre for Ageing Better, Level 3, Angel Building, 407 St John Street, London, EC1V 4AD, UK.
Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Division of Evidence-Based Medicine (dEBM), Charitéplatz 1, 10117, Berlin, Germany.



Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions.


We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data.


Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions.


Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Øvretveit's cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.


Commissioning; Commissioning cycle; Coordinated care; Health and social care integration; Integrated care; Large-scale change; National Health Service; Planning; Purchasing

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