Table 1 Six media of power exercised in commissioner-provider relationships

Medium 1 – Negotiated order (relationality)

Conflicts are managed to produce a “negotiated order” [11]. The emphasis is on relationality [12]. Negotiated order is characterised by explicit or tacit mutually agreed arrangements between commissioners and providers about their involvement in and responsibilities for commissioning. Such mutually agreed arrangement might relate to information sharing and the division of labour, for example.

Medium 2 – Provider competition (contestability)

This medium of power relates to commissioners’ attempts to manage competition between providers [13]. Three key features of this include the criteria for selecting providers, the range of providers and monopsonisation - buyer-side monopoly [14]

Medium 3 – Financial incentives

Commissioners may employ a number of financial incentives to influence provider behaviours. These may relate to units of payment [15], timing of payment, terms and conditions, bonuses, penalties and exemptions [16].

Medium 4 – Ideological and disciplinary control (professional and political ideologies)

Ideological and disciplinary controls through discursive “orders” may be employed by commissioners in their negotiations [17–19]. For example these might relate to technical or scientific knowledge (such as evidence based practice), occupational ethos and norms of conduct, political and economic belief-systems and appeals to higher managerial and political authority such as “targets”, regulators or managerial elite.

Medium 5 – Juridical governance (contracts and law)

Legal and regulatory mechanisms may be used by commissioners in various ways [20]. This medium of power might refer to contract specifications, the use or threat of coercive enforcement of contracts or legal rights and the use of arbitration.

Medium 6 – Managerial performance of commissioning (managerial performance repertoires)

Commissioners have a range of managerial mechanisms and resources to draw on when negotiating with providers [21]. These include decisions about which stakeholders are involved, the role of external supporting bodies, scrutiny of provider performance, prevailing models of commissioning and delegation of commissioning roles and responsibilities.