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We've been commissioning in the NHS in earnest for well over 20 years and the reality is it is still perceived as bureaucracy rather than a legitimate activity and a legitimate overhead on the total cost of getting effective care to patients. The contrast with the private sector is stunning. Any activity that is worth doing within an overall value chain to achieve an objective should be properly resourced. Good commissioning enhances quality and efficiency. Do you remember the Alan MIlburn buzz? "We've invested in providers and now we need to invest in commissioning". Plus ca change. The NHS will always fail unless someone puts some investment (financial, human and ethical) into the planning, buying, performance managing and improving of healthcare - whether you call it commissioning or something else.