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This paper supports the desire of the UK Government to introduce to the National Health Service the concept of accountability for expenditure. General practice budgets will, for the first time, allow GPs, as purchasers of care, to define the needs of their patients and to arrange for those needs to be met, circumventing the arbitrary limits imposed on providers of care under the present arrangements. Should overspending of budgets occur, other doctors will review the decisions made. If the decisions are supported then it will be clear that the budget was insufficient rather than that the practitioner was profligate. The reverse might apply, but such peer review should not be unwelcome. Budgetary control will allow greater choice for the GP of the nature of 2° care provided for his patients. Trust between doctor and patient need not be undermined — indeed, patients may be more confident that they will not be exposed to inappropriate medical intervention. The responsibilities conferred by GP budgets should be accepted, the opportunities welcomed.

Limited resources must be invested wisely. Society′s humanitarian duty to care must be satisfied as well as the economic imperative to use resources rationally. This cannot properly be achieved by reduction of all considerations to a single number which represents a ratio of health gain to resource cost.

Audit activity is now widespread. There are a range of views about its prime purpose. Unless the audit programme has a clear purpose and direction, it will falter. As commissioning develops, there will be more explicit considerations of standards of care. Those standards will address both the processes of outcomes of care, focusing on effectiveness and appropriateness. They will best be generated by local agreement between purchasers, providers and clinicians, based on the knowledge available through research. Audit can provide a systematic appraisal of practice against such standards, while ensuring confidentiality for individual patients and clinicians. Property resourced, audit can play a valuable role directly linked to the commissioning process, which will ensure that the medical profession is fully engaged in the new dynamics of the NHS.

Licensed clubs in Australia offer a range of types of hospitality, gambling and entertainment. Increased competition is forcing them to reappraise features or attributes of their products in order to ensure that they are marketing the right mix of features to their patrons, both club members and visitors. Uses conjoint analysis in order to examine the utility obtained by patrons from alternative types of food and beverage service, gambling and entertainment at two major clubs. The study indicates value differences between clubs, and between patron groups, providing a basis for segmentation. The findings lead to indicators for club marketing strategy.

Explores purchasing in relation to audit, guidelines and research. Notes that the purchasing function is still embryonic, as the NHS struggles to integrate the new reforms. Notes that the different threads need to be woven into a coherent pattern if the full potential of the NHS reforms is to be realized.

Considers the two issues of the range of health care services and balances within the range. Notes the necessity of conducting a national debate concerning the range and limits of service provision within the health service framework. Stresses the importance of making decisions of balance within the range at local level. Unless there is a rational framework for decision making at both levels, both patients and society itself will suffer from inconsistency, confusion and inequity.

Clinical audit is the analysis of whether a predetermined standard of care is achieved over a given period of time. Evaluation of methods of care is an analysis of the benefits that might be expected to accrue from a particular method of treatment by statistical analysis of observations made on sample populations. The two activities have very different aims and approaches; they should not be confused.

Discusses commissioning community health care and the fact that present mechanisms do not enable commissioning to meet the needs of patients requiring community care relevant to their needs. The focus on efficiency, money and simple activity does not take into account the complex nature of community care and the need to take a variety of factors into account if commissioning is to be effective.

Gives an overview of the major features of the general changes in the UK health care system, and describes how PPP healthcare is taking advantage of those changes in developing and implementing strategies for relations with both hospitals and specialists. Notes that similar issues are faced by public sector purchasers. Points out that many of the initiatives described are being adopted, in one form or another, in health care industries across the world. Suggests that new insights or understandings may be found by seeing and considering those issues and initiatives in the context of health care economies.

Quality should be a central issue in the commissioning and provision of health care. This requires a systematic approach to defining and monitoring quality. Such an approach should address: quality characteristics such as efficiency, accessibility, effectiveness (which may conflict with each other); the several levels at which quality may be specified, from general (across all health care) to specific (particular conditions or patient groups); and the methods of quality monitoring which include documented policies, clinical audit, inspection visits/patient surveys, and routine information returns. Shows how a matrix for quality surveillance can be devised which provides a framework for purchasers and providers to work together in developing quality in health care.