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Commissioning group (government) :

Specifies requirements

Pays bill

Expects to get hounds off their back and someone else to blame for problems.

Benefiting group (GPs, us)

Able to evaluate service against specifications

No input into specifications

No input into payment by results

Contracting group (Crapita, or any other commercial agency) :

Sells service to specifier

Attempts to satisfy payer's needs.

Intermediates (civil service) :

Accountable at a mass level to government (but in practice cannot be criticised)

Commissions contracting group for goverment but are not required to be transparent

So what's the problem ? No realtime feedback to close the loop. Failures have no consequences for the elements in power : the public will blame Crapita, who can ignore it because it doesn't affect their future performance. Same for the government. Civil service had the ability to choose a better contractor and monitor the results, but don't because failure has no consequence. Public suffer because they are powerless.