In a time of increasing competition for clinical services resources, it is imperative that health professionals actively participate in the commissioning process in order to ensure that established clinical standards are not compromised. Introduction of the NHS reforms in the UK in the early 1990s highlighted the difficulties in contracting for a specialised service such as clinical genetics, especially in the absence of a consensus regarding the contract currency. An average block contract price for each new family referred was introduced in Wales in 1992, and data from the subsequent five years show that this charging system is economically feasible and has the advantages of (1) recognising the contribution to care of non-medical personnel on the genetics team, (2) covering follow up including the counselling of relatives, (3) protecting the service from loss of income owing to non-attendance, and (4) providing a basis for negotiation when new services are being proposed to purchasers. Activity data show that while the majority of conditions incur below average cost, the mean cost is influenced by a small number of autosomal dominant and X linked disorders. The cost risk to the provider for seeing families over an extended period is minimal, as the data establish that family files experience an exponential decrease in activation probability over the early years, but this becomes constant later on. The robustness of the system is dependent on accurate baseline data on referral patterns to the service, recording of activity, and staff costs.
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