- Although some of the key planks of the NHS reform programme, such as Payment by Results (PbR) and patient choice, began to take shape from 2003, it is only recently that the Department of Health has begun to publish guidance, aimed at people working within the NHS, that attempts to communicate why the reforms are necessary and how they will mesh together. The first document, Health Reform in England: Updates and Next Steps was published in December 2005. It promised further policy guidance, including the Operating Framework which was published in February 2006. The Commissioning Framework follows this. This latest update identifies three drivers of change within the NHS reform programme: patient-driven through choice, voice and competition; commissioner-driven through contracting, contestability and service redesign; and national-driven through standards, targets, agencies and regulatory approaches.