Introduction

Previous chapters in this volume have highlighted the critical importance of identifying strategies for optimising the use of limited financial resources. The choice of types of support and of providers is vital for efficiency in the long-term care (LTC) system. The broad aim of this chapter is to review changes in the arrangements for commissioning services across OECD countries, to explore the consequences of these changes for the system and to identify lessons for policy and practice. Some of the themes related to commissioning mechanisms, such as the regulation of care markets, multilevel governance and personalisation of service delivery are covered in Chapters Seven, Eight and Twelve in this book.

Examples from a number of OECD countries are employed to illustrate variations in commissioning processes and outputs. Variations exist, for example, in the timing and degree of marketisation, the market shares of public, for-profit and not-for-profit providers, the degree of service user involvement in commissioning decisions and the nature of relationships between purchasers and providers. However, comparable information currently available on commissioning LTC in OECD countries is uneven and incomplete. Consequently, this chapter draws together data from a variety of sources, including the OECD, the European Commission and recent research in the area.

The chapter is organised as follows. In the next section we give an overview of changes in the arrangements for commissioning services in different countries, briefly describing different approaches to commissioning as well as its conceptualisation in this chapter. The different market and related mechanisms in the LTC sectors of several OECD countries are then described, with further elaboration on the purchaser–provider split. We go on to explore changes in the balance between different types of providers (public, for-profit and not-forprofit). The outsourcing of services triggered the more widespread emergence of tendering and contract management processes to handle purchaser–provider transactions and associated relationships, and these developments are discussed next. Marketisation also brought greater emphasis on consumer/user choice in the LTC sector, and we look at the advantages and challenges of more recent commissioning models involving users as co-producers and budget holders. We then explore the consequences of these changes for cost-effectiveness in LTC systems.