ABSTRACT
This chapter reviews the difficulties of decision making in an environment of multiple constraints, conflicting values and limited room for manoeuvre. Health authorities manage and coordinate groups of organisations, which together make up a health community. They are charged with delivering governmental priorities by catalysing local action to improve health, reduce health inequalities, integrate services for patients and improve service quality. Effective commissioning needs to recognise the particular health needs of the population served, understand the priorities of both national government and local communities, and appreciate the relative contribution and costs of the services needed to deliver the agreed outcomes. Internationally, there have been a number of systematic attempts to use rational health economics based approaches for the allocation of resources. Most decisions, however, are much more complex and require a series of judgements to be made about a range of trade-offs.
