One of the most important aspects of commissioning, as we saw in Chapter 4, is the ability to develop or evolve a market for those elements that are not provided or are not provided well. Defining a ‘market’ demands that we consider basic aims and institutions. If the aim of the health service is to reduce cost, there will (probably) be an impact on quality. If the aim of the service is to ensure quality this will have an impact on costs. To make sense of this conundrum, the QIPP model (Department of Health, 2009) identified four key elements: quality, innovation, productivity and prevention. If we cut innovation (other than through ‘lean’ or similar methodologies) and prevention (other than for the most obvious elements of Health and Well-being) we can then concentrate on quality and productivity. Whether a quality and productivity strategy is better served by continued collective care, or by proportionate market development, will be discussed below.

Markets in health and social care, or at the very least the way they are described here, are fundamentally about values. We can see this in the way that markets have been discussed recently by the government, local authorities and health services. In describing market-led arrangements we note that patients and service users discuss the ‘values’ of those providing care and support; the way that priority setting processes place values centrally in making decisions about the availability of a treatment; or the emphasis of hospital Chief Executives on discharge criteria. Markets are a good example of values-in-action. Holding to the idea of NHS and social care as collective provision supported by a covenant between the government and people is an attractive idea; conversely markets are a way of achieving ‘best value’ through competition. Collective care supports equality; markets support innovation.