Purchasing for quality: still in the starting blocks?

The NHS is now in its third year of contracting. We are repeatedly told by the Department of Health that purchasing is "the main vehicle for achieving better health and better health services."' To what extent are health authorities in a position to ensure more equitable distribution of health by commissioning the most appropriate package of high quality and value for money services?"2 Below I advance the thesis that, although some progress is being made in purchasing for efficiency, it is proving more difficult for other dimensions of quality, particularly appropriateness. On the national and international level we await a verdict on the effects of the introduction of competitive principles into health care systems.3 Gains in what is described as "efficiency" may need to be set against reduction in access to health care and greater inequity in service delivery.4 At the local level the enormous pace of organisational change makes it hard to tease out the contribution of purchasing itself to changes in the quality of service delivery. In any case, for providers several forces are already driving quality, such as postgraduate and continuing education, medical and clinical audit, and accreditation. Although the potential of the internal market to contribute is clear, it is less clear whether the quality specifications in contracts yet seep into the hearts and minds of those delivering care. There is a risk that they will remain as they started a bureaucratic irritant, for which a quarterly submission to the purchaser called "quality monitoring report," cobbled together by a manager who is second in line, provides adequate balm. There are several reasons. Three merit emphasis: financial pressures; the shortcomings in the information on hospital and community activity; and, at least by standards in the United States (US), the poor state of development of indicators for "appropriate care."