Published: 05/09/2002, Volume II2, No. 5812 Page 12

The most important feature of the 1990s Working for Patients reforms carried forward into New Labour's 'New NHS'was the separation of organisations that provided services from those that procured them. Originally christened the 'purchaser-provider split', this separation postulated that if organisations responsible for service delivery did not have to account directly to an external commissioner (who acted as funder, contractor, and performance manager), they might be tempted to serve their own needs rather than those of the population they served.

The idea formed the backbone of the fundholding era, was reinforced in GP commissioning and built into the heart of the new primary care organisations.

This was in notional form in primary care groups, but more formally at the core of primary care trusts. So what is happening to commissioning?

Commissioning lies at one end of a spectrum that also encompasses contracting and purchasing. Using a culinary analogy, contracting may be equated to the fixed menu: buy all the meals you like, but there is never any choice as far as the food is concerned. Purchasing resembles the table d'h¶te: there is some choice, but determined largely by the chef 's repertoire of dishes. Commissioning is limited only by your imagination: it is the equivalent of asking the chef to recreate that wonderful dish you once had on holiday somewhere in France... it helps if you can remember the recipe, and, of course, any good chef will suggest ways of improving it. But essentially you as commissioner are the driver, and the chef 's role as provider is to fulfil your request.

Even within the metaphor, there are constraints on commissioning. It doesn't make sense to ask a vegetarian restaurant to make you a steak tartare, just as it is probably not reasonable to expect a local general hospital to carry out brain surgery. And it would be difficult for a restaurant to produce steak if you insisted that they couldn't use beef, just as trusts find it challenging to respond to commissioners' strategies without being allocated the appropriate resources.

Yet commissioning in the NHS does have Alice in Wonderland qualities: more and more money poured into the system that seems to evaporate; more and more activity within ever-tighter resources; much-professed local freedom, but only to deliver a centrally driven agenda; dramatic culture changes for over a million employees every year or so; political manoeuvring that would put Alice's Caucus race to shame;

and a rising public expectation.

Typical restaurant constraints of hygiene and local fish prices seem mundane by comparison.

Perhaps more significant is that NHS customers (the public or commissioning PCTs) often do not have the leeway or sophistication to ask providers to produce new recipes, but are more likely to be led by their trusts'menu list - there is rarely any real commissioning option, only a purchasing one. And unlike restaurants, which can replace one recipe with another, NHS providers carry infrastructure burdens; changing a clinical service is like dismantling the cooker, sacking the staff and redecorating the venue.

These factors may help explain the silence that seems to surround commissioning in many parts of the country.Other constraints include PCTs' requirement to understand the diversity of their roles as they take on the provision of all primary and community care (to say nothing of dentistry, optometry, pharmacy, and estates management) and the procurement of just about everything else; a shortfall in management capacity (ie people); and a worse shortage of capability (where and how did anyone in the NHS ever learn about true commissioning? ).

There is also the lack of ownership among clinicians of central NHS priorities (waiting lists have a notorious lack of credibility among doctors); the lack of room to pause and take stock, develop ideas and approaches, or catch up with best practice; and the virtual impossibility of disinvesting resources from one part of the NHS before developing a replacement.

Until at least some of these factors are overcome, the NHS has about as much chance of becoming a needs-driven, commissioning-led organisation as McDonald's has of becoming Maxim's famous Parisian temple to haute cuisine.Oh, and make that large, and to take out...

Jonathan Shapiro is a senior fellow at Birmingham University's health services management centre.