title: What happens when GPs engage in commissioning? Two decades of experience in the English NHS.
abstract: OBJECTIVE
  To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere.
  
  
  METHODS
  A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed.
  
  
  RESULTS
  The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with 'virtuous cycles' (experience of being able to make changes feeding back to encourage greater engagement) and 'vicious cycles' (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues.
  
  
  CONCLUSIONS
  Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.
authors.affiliation: PhD Student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK rosalind.miller@lshtm.ac.uk.
authors.forename: Rosalind
authors.initials: R
authors.lastname: Miller
authors.affiliation: Professor of Health Policy, Centre for Health Services Studies, University of Kent, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Peckham
authors.affiliation: Research Fellow, Centre for Primary Care, University of Manchester, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Coleman
authors.affiliation: Research Associate, Centre for Primary Care, University of Manchester, UK.
authors.forename: Imelda
authors.initials: I
authors.lastname: McDermott
authors.affiliation: Professor of Social Policy, Centre for Primary Care, University of Manchester, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Harrison
authors.affiliation: Reader in Health Policy and Primary Care, Centre for Primary Care, University of Manchester, UK.
authors.forename: Kath
authors.initials: K
authors.lastname: Checkland
mesh_terms: D017598:Efficiency, Organizational; D058005:General Practitioners / Q000458:organization & administration*; D006801:Humans; D010819:Physician's Role; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000458:organization & administration*; D017009:Professional Autonomy; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom
keywords: GP commissioning; primary care organizations; primary care purchasing