Centralised procurement for the health care sector -- bang for your pound or siphoning off scarce resources?

The National Health Service (NHS) has been running a centralised model for health care procurement in England for a few years now. The current system resulted from a redesign of the NHS supply chain that has been operational since 2019 [for details, see A Sanchez-Graells, ‘Centralisation of procurement and supply chain management in the English NHS: some governance and compliance challenges’ (2019) 70(1) NILQ 53-75.]

Given that the main driver for the implementation and redesign of the system was to obtain efficiencies (aka savings) through the exercise of the NHS’ buying power, both the UK’s National Audit Office (NAO) and the House of Commons’ Public Accounts Committee (PAC) are scrutinising the operation of the system in its first few years.

The NAO published a scathing report on 12 January 2024. Among many other concerning issues, the report highlighted how, despite the fundamental importance of measuring savings, ‘NHS Supply Chain has used different methods to report savings to different audiences, which could cause confusion.’ This triggered a clear risk of recounting (ie exaggeration) of claims of savings, as detailed below.

In my submission of written evidence to the PAC Inquiry ‘NHS Supply Chain and efficiencies in procurement’, I look in detail at the potential implications of the use of different savings reporting methods for the (mis)management of scarce NHS resources, should the recounting of savings have allowed private subcontractors to also overclaim savings in order to boost the financial return under their contracts. The full text of my submission is reproduced below, in case of interest.

nao’s findings on recounting of savings

There are three crucial findings in the NAO’s report concerning the use of different (and potentially problematic) savings reporting methods. They are as follows:

DHSC [the Department of Health and Social Care] set Supply Chain a cumulative target of making £2.4 billion savings by 2023-24. Supply Chain told us that it had exceeded this target by the end of 2022-23 although we have not validated this saving. The method for calculating this re-counted savings from each year since 2015-16. Supply Chain calculated its reported savings against the £2.4 billion target by using 2015-16 prices as its baseline. Even if prices had not reduced in any year compared with the year before, a saving was reported as long as prices were lower than that of the baseline year. This method then accumulated savings each year, by adding the difference in price as at the baseline year, for each year. This accumulation continued to re-count savings made in earlier years and did not take inflation into account. For example, if a product cost £10 in 2015-16 and reduced to £9 in 2016-17, Supply Chain would report a saving of £1. If it remained at £9 in 2017-18, Supply Chain would report a total saving of £2 (re-counting the £1 saved in 2016-17). If it then reduced to £8 in 2018-19, Supply Chain would report a total saving of £4 (re-counting the £1 saved in each of 2016-17 and 2017-18 and saving a further £2 in 2018-19) […]. DHSC could not provide us with any original sign-off or agreement that this was how Supply Chain should calculate its savings figure (para 2.4, emphasis added).

Supply Chain has used other methods for calculating savings which could cause confusion. It has used different methods for different audiences, for example, to government, trusts and suppliers (see Figure 5). When reporting progress against its £2.4 billion target it used a baseline from 2015-16 and accumulated the amount each year. To help show the savings that trusts have made individually, it also calculates in-year savings each trust has made using prices paid the previous year as the baseline. In this example, if a trust paid £10 for an item in 2015-16, and then procured it for £9 from Supply Chain in 2016-17 and 2017-18, Supply Chain would report a saving of £1 in the first year and no saving in the second year. These different methods have evolved since Supply Chain was established and there is a rationale for each. Having several methods to calculate savings has the potential to cause confusion (para 2.6, emphasis added).

When I read the report, I thought that the difference between the methods was not only problematic in itself, but also showed that the ‘main method’ for NHS Supply Chain and government to claim savings, in allowing recounting of savings, was likely to have allowed for excessive claims. This is not only a technical or political problem, but also a clear risk of siphoning off NHS scarce budgetary resources, for the reasons detailed below.

Submission to the pac inquiry

00. This brief written submission responds to the call for evidence issued by the Public Accounts Committee in relation to its Inquiry “NHS Supply Chain and efficiencies in procurement”. It focuses on the specific point of ‘Progress in delivering savings for the NHS’. This submission provides further details on the structure and functioning of NHS Supply Chain than those included in the National Audit Office’s report “NHS Supply Chain and efficiencies in procurement” (2023-24, HC 390). The purpose of this further detail is to highlight the broader implications that the potential overclaim of savings generated by NHS Supply Chain may have had in relation to payments made to private providers to whom some of the supply chain functions have been outsourced. It raises some questions that the Committee may want to explore in the context of its Inquiry.

1. NHS Supply Chain operating structure

01. The NAO report analyses the functioning and performance of NHS Supply Chain and SCCL in a holistic manner and without considering details of the complex structure of outsourced functions that underpins the model. This can obscure some of the practical impacts of some of NAO’s findings, in particular in relation with the potential overclaim of savings generated by NHS Supply Chain (paras 2.4, 2.6 and Figure 5 in the report). Approaching the analysis at a deeper level of detail on NHS Supply Chain’s operating structure can shed light on problems with the methods for calculating NHS Supply Chain savings other than the confusion caused by the use of multiple methods, and the potential overclaim of savings in relation to the original target set by DHSC.

02. NHS Supply Chain does not operate as a single entity and SCCL is not the only relevant actor in the operating structure.[1] Crucially, the operating model consists of a complex network of outsourcing contracts around what are called ‘category towers’ of products and services. SCCL coordinates a series of ‘Category Tower Service Providers’ (CTSPs), as listed in the graph below. CTSPs have an active role in developing category management strategies (that is, the ‘go to market approach’ at product level) and heavily influence the procurement strategy for the relevant category, subject to SCCL approval.

03. CTSPs are incentivised to reduce total cost in the system, not just reduce unit prices of the goods and services covered by the relevant category. They hold Guaranteed Maximum Price Target Cost (GMPTC) contracts, under which CTSPs will be paid the operational costs incurred in performing the services against an annual target set out in the contract, but will only make a profit when savings are delivered, on a gainshare basis that is capped.

Source: NHS Supply Chain - New operating model (2018).[2]

04. There are very limited public details on how the relevant targets for financial services have been set and managed throughout the operation of the system. However, it is clear that CTSPs have financial incentives tied to the generation of savings for SCCL. Given that SCCL does not carry out procurement activities without CTSP involvement, it seems plausible that SCCL’s own targets and claimed savings would (primarily) have been the result of the simple aggregation of those of CTSPs. If that is correct, the issues identified in the NAO report may have resulted in financial advantages to CTSPs if they have been allowed to overclaim savings generated.

05. NHS Supply Chain has publicly stated that[3]:

  • ‘Savings are contractual to the CTSPs. As part of the procurement, bidders were asked to provide contractual savings targets for each year. These were assessed and challenged through the process and are core to the commercial model. CTSPs cannot attain their target margins (i.e. profit) unless they are able to achieve contractual savings.’

  • ‘The CTSPs financial reward mechanism [is] based upon a gain share from the delivery of savings. The model includes savings generated across the total system, not just the price of the product. The level of gain share is directly proportional to the level of savings delivered.’

06. In view of this, if CTSPs had been allowed to use a method of savings calculation that re-counted savings in the way NAO details at para 2.4 of its report, it is likely that their financial compensation will have been higher than it should have been under alternative models of savings calculation that did not allow for such re-count. Given the volumes of savings claimed through the period covered by the report, any potential overcompensation could have been significant. As any such overcompensation would have been covered by NHS funding, the Committee may want to include its consideration within its Inquiry and in its evidence-gathering efforts.

__________________________________

[1] For a detailed account, see A Sanchez-Graells, “Centralisation of procurement and supply chain management in the English NHS: some governance and compliance challenges” (2019) 70(1) Northern Ireland Legal Quarterly 53-75.

[2] Available at https://wwwmedia.supplychain.nhs.uk/media/Customer_FAQ_November_2018.pdf (last accessed 12 January 2024).

[3] Ibid, FAQs 24 and 25.

More UK procurement deregulation proposals, this time for healthcare [catching up with the proposed new provider selection regime for NHS England]

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I came back from shared parental leave a couple of weeks ago and have been trying to catch up with the last six months’ worth of developments in the regulation of procurement in the UK and the EU. I do not even dare write down the list of instruments and proposals to consider … It seems that it has been a half year full of procurement news. I hope you have all been keeping well and abreast of so much change!

One of the relatively recent developments is the February 2021 proposal for the replacement of the current rules on the commissioning of healthcare services for the purposes of the English national health service (NHS England) with a new provider selection regime (‘the proposal’). There was a public consultation on the proposal that closed in April, so I am coming late to the party. However, I think there is still some point in jotting down a few critical comments, as the likelihood that the future secondary legislation deviates from the proposal seems minimal.

Background

By way of background, it is worth saying that NHS commissioning is a peculiar procurement activity resulting from the creation of an NHS internal market in the 1990s with the aim of harnessing market incentives and competition-based governance to improve the efficiency of the English healthcare system (see here). NHS commissioning takes place in a largely in-house environment where NHS buyers commission services primarily from NHS suppliers, but also with mixed private participation by both for-profit and third sector providers (for further background, you can watch here). Discussion of the rules on NHS commissioning is always tarnished by the linked controversy on the privatisation of the NHS (for a good explainer, see here).

NHS commissioning is currently subjected to both the Public Procurement Regulations 2015 (PCR2015, aka the UK’s copy-out transposition of Directive 2014/24/EU) and the National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013. The proposal seeks to take NHS commissioning out of the scope of application of the PCR2015 — which is possible, given the exclusion of healthcare services from the UK’s schedules of coverage under the WTO GPA, as well as the explicit exclusion of healthcare services from the EU-UK TCA (see Annex 25) — and to repeal the 2013 Regs. NHS Commissioning would then be subjected to a new provider selection regime described (at a high level of generality) in the proposal.

The proposal thus continues with the de-regulatory approach already taken in the 2019 legislative proposals to implement the NHS Long-term Plan, and seeks to dismantle large chunks of the market-based regulation of the NHS internal market, which is a political aspiration of both current UK Government and opposition and, to some extent, is also seen as a Brexit dividend — though I have argued it is not, and that the proposal is undesirable, not least because most of what it seeks to achieve is possible under the current EU-based procurement rules of the PCR2015 (see here). It should be noted that the proposal runs in parallel to the also de-regulatory approach underpinning the December 2020 green paper Transforming Public Procurement [on which see here, here, and here, while we wait for the Government’s response to the public consultation].

Key elements of the proposal

In a nutshell, the proposal seeks to debunk tendering as the sole (or rather, primary, for there are exceptions in reg.32 PCR2015) mechanism for the award of healthcare contracts, and to create three routes to contract award (for a quick overview see e.g. here, or here). This is the first fundamental area of change in the proposal, which would create an ‘NHS-specific’ set of procurement rules. Those ‘new’ routes would be: (route 1) contractual extension/renewal with the incumbent provider; (route 2) NHS commissioner’s non-competitive unilateral determination of the most suitable provider; and (route 3) competitive procurement. Competitive procurement would not necessarily be tightly regulated in detail, but rather subjected to some principles or basic requirements detailed in the proposal (point 5.9), which would require decision-making bodies to:

  • have regard to relevant best practice and guidance; for example, HM Treasury’s managing public money guidance

  • ensure the process is transparent, open and fair (original emphasis)

  • ensure that any provider that has an interest in providing the service is not part of any decision-making process (...)

  • formally advertise an opportunity for interested providers to express interest in providing the service

  • compare providers against the criteria set out in the regime and any other relevant factors, and according to any hierarchy of importance they decide is necessary – which must be published in advance

  • publish their intention to award the contract with a suitable notice period (eg 4–6 weeks unless a shorter period is required due to the urgency of the case).

In choosing across routes and in making decisions within a given route, commissioners would have to ‘ensure that services are arranged in the best interests of patients, taxpayers and the population’, and would have to follow the ‘key criteria’ of: (a) Quality (safety, effectiveness and experience) and innovation; (b) Value; (c) Integration and collaboration; (d) Access, inequalities and choice; and (e) Service sustainability and social value. Each of these criteria are explained in more detail in the proposal’s Annex.

Other than compliance with the above key criteria, the regime would primarily only impose transparency (and standstill) obligations on NHS commissioners (see part 8 of the proposal). This is the second fundamental area of change in the proposal. Notably, ‘Where contracts are being continued or rolled over, or a change in providers is being considered, decision-making bodies must publish their intended approach in advance’ (point 8.2). Specifically, commissioners have a duty to publish their intended decisions ‘with a suitable notice period (eg 4–6 weeks unless a shorter period is required due to the urgency of the case)’ in all cases, save (apparently) in the rollover of contracts to incumbent providers where the type of service means there is no alternative provision (point 5.5.A), or where the alternative provision is already available to patients through other means such as the exercise of patient choice (point 5.5.B).

During that notice (and standstill) period, ‘representations can be made to the decision-making body once it has published its decision. Judicial review would be available for providers that want to challenge the lawfulness of the decision’ (point 8.3). The proposal further establishes that ‘If representations objecting to the process or outcome are received from other providers in that time, the decision-making body must: i. discuss the issue with the providers or their representatives[; and] ii. publish a response to the objections before the award, setting out its decision to either: (a) not to proceed with the contract award as intended and reconsider its process and/or decision; or (b) award the contract as intended and publish reasons for so proceeding as part of the contract award procedure’ (point 8.6). Presumably, the avenue to judicial review challenges open up here — as disappointed providers can reasonably be expected to exhaust the possibility of complaining to the commissioner before launching legal proceedings.

Comments on the ‘three route’ model

Tendering optionality. Under the proposal, competitive tendering would become optional for NHS commissioners: ‘It would be for the decision-making body to decide when a competitive procurement is the most appropriate means to select a provider‘ (point 5.9). Further, in general, there is a strong anti-tendering narrative underpinning the proposal that somewhat comes to make competitive tendering the mechanism of last resort — to be applied only where ‘after considering the key criteria the decision-making body does not identify a single candidate that is the most suitable provider, and/or concludes that the most suitable provider can only be identified by carrying out a competitive procurement‘ (ibid). This seems to leave open the possibility for a commissioner unable to identify a single best candidate to still consider that tendering is not the way to identify it — in which case there could be space for a ‘fourth’, completely unregulated, route to contract award (surely that is not the intention, though!). Additional, clear (and restrictive) criteria supporting a decision not to use competitive tendering seem necessary.

Rolling out contracts. Why create such a regulatory black hole? From a practical perspective, the main problem with route 1 (direct award of a contract extension/renewal) is that it covers two very different sets of circumstances. One where the optionality of tendering is uncontroversial, and one where it can be extremely problematic.

Regarding the first set of circumstances, it should be stressed that two of the grounds for the use of direct contractual extension/renewal with the incumbent provider (route 1) already exclude the need for a tender under the current rules. Where there there is no alternative provision (route 1A), there is no obligation to tender (see reg.32(2)(b)(ii) CR2015). Where the service is to be provided under a patient choice mechanism (ie where specific choice is not exercised by the commissioner), the inclusion of providers in the relevant ‘any qualified provider’ list is not covered by the scope of the procurement rules (reg. 2 PCR2015, incorporating the definition of “procurement” in Art 1(2) Dir 2014/24, as interpreted by the CJEU in Falk Pharma and Tirkkonen). Moreover, the proposal includes specific rules on the management of such lists (points 7.7 and 7.8).

Conversely, route 1C encompasses a set of circumstances that makes the possibility of a direct award quite worrying and potentially very problematic. Indeed, route 1C foresees that ‘If a decision-maker wants to continue with existing arrangements, they may do so where: … C) The incumbent provider/group of providers is judged to be doing a sufficiently good job (ie delivering against the key criteria in this regime) and the service is not changing, so there is no overall value in seeking another provider’ (point 5.5, emphasis added). The test for establishing that a provider is ‘doing a sufficiently good job’ not only seems too open-ended (it may be the informality with which this part of the proposal is drafted), but also defies logic.

If the incumbent’s contract was designed to deliver against the regime’s key criteria (and it should otherwise not be in place, to begin with), compliance with the contract cannot be grounds for its renewal. It should be the other way around: failure to meet the contractual requirements should lead to contract renegotiation or termination. But the mere fact that a contract is being complied with should not generate legal grounds for its (indefinite) extension. Not least because the opportunities for rent-seeking and corruption that this option generates are precisely the reason why public contracts cannot be perpetual and why there have to be external checks on both the commissioner and the provider.

Moreover, given the transparency and standstill obligations controlling the rollout of contracts, it is very likely that any such arrangement will be challenged by potential alternative suppliers (leading to a waste of time, see below). It is hard to see how a system that is premised on the need for potential alternative suppliers to have to actively challenge (and litigate?) contract rollout benefitting the incumbent provider can be considered a ‘decision-making process that makes space for real collaboration to happen; that does not frustrate integration by creating adversarial relationships’ as the proposal claims to intend (point 1.5). It is hard to see how the judicial review of this type of decision could be effected, as the relevant test (the provider is ‘doing a sufficiently good job’) seems to lay squarely within the technical discretion of the commissioner. If that is true (or once that is established in case law), then there may be no point in challenging or litigating contract rollout, which would simply result in a regulatory black hole.

Are there really alternatives to tendering where there is service change or the incumbent needs to be replaced? Where rolling out contracts is not an option, the optionality of tendering can be doubted in practical terms.

The only way to avoid competitive procurement where ‘the decision-making body is changing a service/existing contract considerably; a brand new service is being arranged; the incumbent no longer wants to or is no longer able to provide the services; or the decision-making body wants to use a different provider’, is for ‘the decision-making body [to have] reasonable grounds to believe that one provider/group of providers is the most suitable provider (which may or may not be the incumbent), they may award the contract directly’ (point 5.8). Reaching this reasonable determination requires the commissioner to ‘be satisfied that they can justify that the provider they are proposing to select is the most suitable provider by reference to the criteria set out in the regime and any other relevant factors, and according to any hierarchy of importance the decision-making body decides is necessary' and 'have carefully considered other potential options/providers within the relevant geographical footprint' (ibid).

How exactly this is possible without the information-revelation process of a competitive tendering is quite difficult to fathom. The proposal seems to presume a level of (dynamic, updated) market intelligence on commissioners that seems quite an implausible standard. Further, such an approach is at odds with the proposal’s stated goal of wanting to promote innovation (indeed, one of the key criteria requires ‘Ensuring decision-making bodies seek to innovate and improve services delivered by either existing or new providers, proactively developing services that are fit for the future’). Innovation must necessarily be co-produced (if not market-led) in this context — as recognised in the Annex to the proposal: ‘Decision-making bodies should give due consideration to any particular innovative approaches offered by providers that could help to deliver better outcomes, and avoid assuming that what is currently provided will match current or future need’. Unless commissioners have a crystal ball, this can only be done through proper market engagement and there is no clear reason why that engagement cannot be effectively channelled through competitive procurement.

Moreover, once again, given the transparency and standstill obligations and the likelihood of challenge, is it reasonable to expect any commissioner to engage in such non-competitive unilateral determination with limited information?

No time to waste, or risk aversion? In both routes 1 and 2, there is a presumption that ‘given that the commissioner knows best’, there is no need to subject contract award to competitive tendering. In the slightly more elegant words of the proposal:

‘In practice, the bulk of current NHS services are arranged without competitive processes or tendering (though this approach is sometimes not without legal risk). There is a justifiable reason for this. … in many circumstances the choice of service provider will be constrained by the nature of the service and its interdependencies with other services. Our proposed regime explicitly recognises this reality and makes it clear that such core NHS services can be arranged without NHS decision-making bodies being pushed through valueless bureaucratic exercises’ (para 5.2).

The real reason for the proposed approach is then not to avoid useless competitive tendering — which is not taking place anyway — but to rid NHS commissioners from legal risk. Well, two comments seem warranted here. The first one is that legal risk is not at all reduced in the proposal. Both routes 1C and 2 are riddled with open-ended legal concepts and commissioners willing to rely on them will have to accept legal risks no smaller than those implicit in findings that a service is to be directly awarded to a sole-source provider (which is presumably the legal risk the proposal indirectly refers to).

The second one is that the way this legal risk is to be excluded — ie via transparency and standstill — can generate a significant delay (of 4 to 6 weeks) in the launch of a competitive tendering procedure where the commissioner’s approach is challenged. A competitive tendering procedure that could, by the way, last less than 6 weeks — were it not for the proposal’s double transparency requirement of advertising the contact opportunity and then also imposing a 4-6 week standstill prior to award (which much extends the current standstill obligation under the PCR2015).

Of course, commissioner’s may decide to dismiss challenges, reaffirm their decisions, and carry on. The question then becomes what remedies are available to disappointed providers at the stage of judicial review. If damages enter the picture (and they may), the accumulated disincentive of delay and liability exposure can hardly provide a more comfortable mix than the current rules — or the foreseen cap on damages for procurement litigation under the green paper proposals, for that matter.

There's more than one way to skin a cat. Much like the green paper, the proposal is deceptively simple in the deregulation of route 3 and the subjection of competitive tendering to minimum principle-based requirements. Given the likelihood that route 3 becomes THE route (other than for 1A and 1B awards), it seems too open-ended for the proposal to solely require that commissioners

  • have regard to relevant best practice and guidance; for example, HM Treasury’s managing public money guidance

  • ensure the process is transparent, open and fair (original emphasis)

  • ensure that any provider that has an interest in providing the service is not part of any decision-making process (...)

  • formally advertise an opportunity for interested providers to express interest in providing the service

  • compare providers against the criteria set out in the regime and any other relevant factors, and according to any hierarchy of importance they decide is necessary – which must be published in advance

Unless the expectation is for a single competitive tendering procedure to be created in secondary legislation — but this is not the obvious implication of the proposal, and would run counter to the approach to eg transposing the rules on the award of social and special services contracts (see reg.76 PCR2015) — each commissioner would be free to create its own procedure. This would in fact subject NHS competitive tendering to the same ‘anti-procedure’ regulation envisaged for the competitive flexible procedure in the green paper. And it would thus open it up to the same criticism, on the basis of the explosion of transaction costs (as well as legal uncertainty) it would create. Allow me a cross-reference to the points made in my response to the green paper’s consultation.

Conclusion

To put it simply, by following the lead of the green paper and seeking to deregulate NHS commissioning, the proposal can generate very negative unwanted effects in terms of the cost, complexity and exposure to challenge and litigation of the system. In my view, it would mainly create an ex ante layer of accountability that (while welcome in principle) would burden commissioners and in most cases result in the tendering of contracts anyway, but subject to under-specified rules. How this can be seen as an improvement over the current situation escapes my imagination.

Healthcare procurement: a service of general economic interest?

With thanks to Dr Mary Guy (Lancaster University) for the invitation to speak at her innovative ‘Health in Europe - Virtual Discussion Forum’, below is the recording of my presentation on the treatment of healthcare procurement as a service of general economic interest. The slides are also available.

The presentation explores the case study of the English NHS Supply Chain (for a detailed account of how it works, please see here). However, broader issues of potential relevance in EU jurisdictions considering ways of reforming (and centralising) healthcare procurement are also explored.

This is work in progress for me, so comments most welcome: a.sanchez-graells@bristol.ac.uk.

As a side note, it is worth stressing that NHS Supply Chain is currently under fire due to its failure to react properly to the PPE challenges derived from the COVID-19 crisis after a scathing National Audit Office report (on which you can watch some comments here).

NHS commissioning and procurement - 2 short lectures and a reading list

I have recorded a series of short lectures on NHS commissioning and procurement for my blended teaching at the University of Bristol Law School this coming academic year. In case they are of any interest, I am sharing two of them here.

The first one covers the organisation and regulation of NHS commissioning and procurement and primarily concentrates on the commissioning of health care services. The second lecture covers the centralisation of ‘hospital procurement’ through the NHS Supply Chain. They should be accessible through the click-through images at the end of the blog post.

The two short lectures aim to provide a (hopefully) accessible introduction to the issues covered in more detail in the accompanying reading list, which mainly comprises the following papers for each of the topics:

1. Organisation and regulation of NHS internal market, with a focus on commissioning and procurement

  • A Maynard and M Dixon, ‘Should the NHS abolish the purchaser-provider split?’, BMJ 2016;354:i3825, available at https://doi.org/10.1136/bmj.i3825.

  • C Paton, ‘Garbage-Can Policy-Making Meets Neo-Liberal Ideology: Twenty-five years of redundant reform of the English National Health Service’ (2014) 48(3) Social Policy & Administration 319-342.

  • L Jones, M Exworthy and F Frosini, ‘Implementing Market-based Reforms in the English NHS: Bureaucratic coping strategies and social embeddedness’ (2013) 111(1) Health Policy 52-59.

  • B Collins, ‘Procurement and Competition Rules. Can the NHS be exempted?’ (2015) King’s Fund briefing, available at https://www.kingsfund.org.uk/publications/nhs-procurement-competition-rules.

  • M Guy, ‘Between “Going Private” and “NHS Privatisation”: Patient choice, competition reforms and the relationship between the NHS and private healthcare in England’ (2019) 39(3) Legal Studies 479-498.

  • P Allen et al, ‘Public Contracts as Accountability Mechanisms: Assuring quality in public health care in England and Wales’ (2016) 18(1) Public Management Review 20-39.

  • D Osipovič et al, ‘Interrogating Institutional Change: Actors' Attitudes to Competition and Cooperation in Commissioning Health Services in England’ (2016) 94(3) Public Administration 823-838.

  • P Allen et al, ‘Commissioning through Competition and Cooperation in the English NHS under the Health and Social Care Act 2012: Evidence from a qualitative study of four clinical commissioning groups’, BMJ Open 2017;7:e011745, available at http://dx.doi.org/10.1136/bmjopen-2016-011745.

  • M Sanderson, P Allen and D Osipovič, ‘The Regulation of Competition in the National Health Service (NHS): what difference has the Health and Social Care Act 2012 made?’ (2017) 12(1) Health Economics, Policy and Law 1-19.

  • D Osipovič et al, ‘The Regulation of Competition and Procurement in the National Health Service 2015–2018: Enduring hierarchical control and the limits of juridification’ (2020) 15(3) Health Economics, Policy and Law 308-324.

2. Centralisation of NHS procurement

Feedback and suggestions on additional readings most welcome: a.sanchez-graells@bristol.ac.uk.