Purchasing for all: an alternative to fundholding

Locality commissioning: how much influence have general practitioners really had?

This paper investigates the various models of locality commissioning in relation to the participation of general practitioners (GPs), and explores the perceived successes of locality commissioning in the 15 health boards in Scotland and 13 health authorities in the Northern and Yorkshire Region of England. A postal questionnaire was sent to 190 individuals involved in commissioning, and semi-structured interviews with GPs (n = 31) and health authority managers (n = 41) were undertaken in each of the 28 health authorities. Seventy-five per cent of the health authorities had introduced some form of locality commissioning. Five types of locality commissioning organization were identified on the basis of the level of GP influence over decisions. All GP responders identified benefits resulting from their involvement in the process but only 27% of health authority responders did so. Most benefits related to improved professional relationships, not to service changes. On the whole, locality commissioning does not appear to have resulted in major changes to contracts or services.

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services

BACKGROUND

General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning.

AIM

To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided.

METHOD

A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received.

RESULTS

Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs.

CONCLUSION

The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.

Fund-holding and contracting for community nursing services: a selective review of the literature

In the context of social, political and economic pressures fund-holding has been described as the 'wild card' in the Health Care Reforms in the United Kingdom of the 1990s. Set against an international drive to reform health care and increase the efficient and effective use of resources, fund-holding by general practice is seen as one means of enhancing the contribution of a primary care led National Health Service (NHS). It is advocated that a primary care led NHS will enhance and strengthen the position of nursing in the health care context. In order to fully exploit such a position it is argued that primary care nurses must adopt a systems view, recognizing broader strategic issues upon which to base marketing approaches to the contracting process.

Alternatives to fundholding

The new Labour government in the United Kingdom is proposing to adapt the reforms begun by the last Thatcher government. In particular, it is proposing to abolish the most controversial element--general practitioner (GP) fundholding. It is looking for alternatives. The study reported here followed and evaluated several such schemes. While fundholders use their purchasing power directly to force change by threatening "exit" to another provider, other GPs have evolved ways of influencing decisions--enhancing their "voice." The authors develop a theory to predict the conditions favoring the relative success of exit and voice strategies in health purchasing, and describe alternative GP-based purchasing schemes and the reasons they evolved in six sample districts. In four of these districts and eight practices in each, fundholding and non-fundholding GPs were then asked to describe their intentions and the outcomes of the purchasing process in which they had participated. Four specialties were taken as examples. The authors compare the relative success of fundholders and non-fundholders in achieving their objectives.

Paradoxes of GP fundholding: contracting for community health services in the British National Health Service

The expansion of GP fundholding (GPFH) is central to the British government's attempt to maintain the revolution under way in the National Health Service (NHS). Evaluations of the NHS reforms have portrayed GPFH as an important mechanism for competition, and GPFH's bargaining power is reported to have secured significant changes in health service provision. However, these developments have been acknowledged to be less applicable in relation to community health services (CHS) than acute hospital services. On the basis of case studies of the process of contracting for CHS, GPFHs are shown to display ambivalent and sometimes contradictory views which have to be related to broader policy developments in general practice and primary care. Although this paper focuses on the British situation, many of the issues raised by reforms in primary and community health services have implications for developments in other Western health care systems.

A stakeholder analysis of developments at the primary and secondary care interface

BACKGROUND

The interface between primary and secondary care has become a major focus of health policy debate, but the differing perspectives of stakeholders on recent developments in policy and practice have seldom been researched.

AIM

To examine stakeholder perspectives on the extent of developments at the primary and secondary care interface, and the barriers and opportunities for future development.

METHOD

This qualitative study was based on semi-structured interviews with a purposive sample of 27 primary and secondary care stakeholders in Southampton and South West Hampshire in 1994. Respondents were asked to identify developments in seven areas: direct access, consultant outreach, shifted services, substituted services, shared care, workload shifts and communication.

RESULTS

Key issues were identified relating to the cultures of primary and secondary care, communication and work-load. Most respondents described an important shift in power from consultants to GPs. Although respondents identified several useful developments at the interface, including improvements in communication and increased direct access facilities, there were relatively few reports of shifts in resources and services to primary care. Respondents identified important continuing barriers to change, including the attitudes of consultants and the individualistic culture of GPs.

CONCLUSION

Policies to "shift the balance' and to further "a primary care-led NHS (National Health Service)' need to address the cultural and political factors which respondents identified as barriers to primary care development.

Has general practice fundholding been good for patients?

This article discusses some of the advantages and drawbacks of GP fundholding from both the patient's and a population point of view. An equitable division of resources should be a major priority of the health service. Evidence to date suggests that there are problems with fundholding. These require evaluation in order to build on the successes and improve in areas of controversy.

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London

OBJECTIVE

To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.

DESIGN

Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.

SUBJECTS

24 inner city, non-training general practices.

SETTING

East London.

MAIN OUTCOME MEASURES

Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."

RESULTS

In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.

CONCLUSIONS

Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.

General practitioner fundholding: weighing the evidence

A new development in the British National Health Service is fundholding, whereby certain general practitioners are given budgets from which they purchase services for patients. Our knowledge about fundholding is rudimentary. Many important questions remain unanswered. These include: the impact of fundholding on the efficiency of overall resource utilisation; its effect on strategic planning; its effect on equity; its impact on the role of the doctor and the doctor-patient relationship; and its consequences for practice organisation and the culture of primary care. Even the scant results we do have must be interpreted cautiously. Fundholding was introduced during a period of great turbulence for general practice. Its strategic function was uncertain and its impact has been confounded by the effects of a series of earlier and concurrent policy changes. Few reliable conclusions about fundholding, either positive or negative, can be drawn from existing research.

What do we known about fundholding in general practice?

The general practice fundholding scheme was introduced four years ago. So far its impact has not been formally evaluated nationally, but review of published research shows some trends. Fundholding has curbed prescribing costs and given general practitioners greater power to lever improvements in hospital services--for example, reducing waiting times for hospital treatment--but fundholding practices may have received more money than non-fundholding practices. The impact of fundholding on transactions costs, equity, and quality of care (particularly for patients of non-fundholding general practitioners) is unknown. Research into costly reforms such as fundholding needs to be coordinated.