A major investigation into the commissioning of health care for people with long-term conditions (LTCs) has questioned the extent to which the NHS internal market in England operates as policymakers intended.

The study examined what commissioners do on a day-to-day basis, focusing on how they sought to develop and improve care for people with diabetes, dementia and stroke, and its most striking finding was the sheer scale of the "labour" of commissioning - the amount of meetings, discussions, planning and analysis that goes into the review and commissioning of often small-scale changes.

Indeed, these findings raise questions as to whether this extensive and resource-hungry "labour" is worth the outcomes secured for patients, say the researchers .

The two-year study of commissioning practice in three high-performing Primary Care Trust (PCT) areas - Calderdale, Somerset and the Wirral - was conducted by health policy think tank The Nuffield Trust, with funding from the National institute for Health Research Health Services and Delivery Research (NIHR HS&DR) Programme.

The researchers found that commissioners were seen to act as the convenor of the local health system. What was less evident was the more transactional or hard-edged part of their role - using data to review and challenge existing service provision, halting the provision of services deemed to be ineffective, or contracting for new forms of care that would lead to significant change in how primary or secondary care are provided.

During a time of austerity, the new clinical commissioning groups (CCGs) will need to make sure that they leave space for the more hard-edged transactional work - eg, specifying contracts, service review, decommissioning - in order to improve outcomes for their populations, the authors advise.

They found less evidence of a robust approach to assessing the performance, quality and impact of local services, or of willingness to provide necessary challenge to existing local providers, says lead investigator Dr Judith Smith, director of policy at The Nuffield Trust.

"With much less money available for NHS management, the new generation of commissioners will need to pay close attention to the cost of their practice, display rigour in setting clear and measurable objectives for a programme of commissioning work, and ensuring that they can demonstrate that their effort is worth the candle," she says, adding: "they need to be mindful of when they need to stop consulting and engaging, and move to the procurement phase of their work - in effect, when to stop talking and cut a deal."

Several themes emerged from the study, including:
- the role of money in commissioning practice was observed to be intermittent and at times peripheral. The organisational structure of PCTs encouraged a separation of financial and contractual aspects of commissioning from developmental processes. A limited role was observed for NHS financial incentive schemes, but the majority of spending on the services studied was absorbed in block contracts;
- changes brought about through the commissioning processes tended to be incremental rather than radical - they were cautious, carefully-paced and non-disruptive. Success seemed to come where commissioners were tackling "bite-sized" commissioning tasks as part of a wider local plan for service delivery; and
- external drivers of commissioning were shown to play a powerful role in shaping commissioning practice. National guidances provided top-down impetus to get things done, templates for services and a national framework to facilitate local decision-making and identification of priorities. External support organisations were available for commissioners to call on to help their work.

The report makes a number of recommendations for effective commissioning, including: - introducing a greater emphasis on priority-setting where decisions are made about how to spend local health budgets; - maintaining a closer eye on the activity, financial performance and quality of services commissioned; and - focusing on the services that consume most of the budget and designing approaches that suit the particular service. An example here would be, for LTCs, to develop contracts that share risk better across the range of providers responsible, and run them to longer time horizons, it says.