Most, if not all, primary care trusts will improve their commissioning competencies over the next few months. This will be an important step towards gearing up commissioning to play its full role.

However, an improvement in capability will not in itself be enough to ensure that commissioning can play its full role in increasing efficiency.

The crisis in acute overspend represents not just a failure to put commissioning plans into action but also a deficiency in commissioners’ contractual tools. The contract gives too much power to the provider to spend money without recourse back to the commissioner.

There are now a number of invoice validation systems which provide commissioners with up to date information on what their money is being spent on in the hospital. They can quickly find out that the hospital had started to stretch the original diagnosis into a range of other procedures.

But commissioners need contracts that then enable them to act on this information. In other systems, payers have the right to agree any extension of procedures beyond the original referral. They can raise questions about how the hospital is treating their patient and spending their money.

Most contracts in the rest of our lives involve the right to agree or disagree when the provider wants to add additional costs. Without the right to stronger interventions, attempts to create efficiency will be severely diminished. It may well be the case that the operating framework will deflate the tariff, so as to save hundreds of millions of pounds in provider spend.

But if the providers can use the contract to increase the volume of their work to make up for the lower price of each procedure, it will mean that by next autumn the system will run out of money.

In 2010-11 there will be none of the usual NHS bungs to sort the system out. We will either have a system where commissioners can control their spend or the NHS will face bankruptcy.

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