General Practitioner Fundholding Research Articles

Encouraging preventive services in primary care through payment schemes

Strengthening the use of preventive services in primary care has become the key to solving the problem of a global increase in healthcare expenditures caused by aging populations and chronic diseases. In practice, whether devoting effort to preventive services can be a strategic decision when the limited working time keeps a general practitioner (GP) busy with diagnosis and treatment. Based on the above motivations and challenges, we are the first to focus on the conflict between treatment services and preventive services of a GP with limited service capacity in the healthcare field. This paper considers a public health system consisting of a funder, a GP, a specialist, and a pool of delay-sensitive residents. Four payment schemes are investigated in terms of encouraging the GP to deliver preventive services: (i) fee for service (FFS), (ii) capitation, (iii) GP fundholding, and (iv) penalty scheme. The result shows that the GP fundholding scheme and the penalty scheme are more effective in encouraging preventive service provision in primary care, whereas the other two schemes may result in underinvestment in preventive services. Further, we compare the performance of the GP fundholding scheme and penalty scheme by applying the optimal reimbursement, which refers to the amount that maximizes social welfare. Compared with the GP fundholding scheme, the penalty scheme can incentivize preventive services with lower expenditures for the funder. There are two additional interesting findings: (1) A larger reimbursement discourages the GP from delivering preventive services. (2) An increased marginal treatment cost always incentivizes the GP to allocate more working time to preventive services, thereby reducing the referral rate and saving costs. Counterintuitively, increasing the marginal cost of preventive services may also encourage the GP to deliver preventive services. Our analysis sheds light on how to encourage preventive service provision in primary care through payment schemes.

The Hungarian Care Managing Organization Pilot Program

ObjectivesThe aim of this article was to provide a description of the Hungarian care managing organization (CMO) pilot program and its environment, incentive structure, and preliminary outcomes. The need to change the behavior of doctors to increase the effectiveness and cost-effectiveness of the system was the key rationale for the Hungarian CMO pilot program. MethodsAfter an application process, nine CMOs were entitled to enter into the system in July 1999. By 2006, there were 14 CMOs covering 2.1 million people. The Hungarian CMO program tried to combine the advantages of both the US managed care programs and the UK general practitioner fundholding system, within the constraints and opportunities of a Central-European country committed to a single-payer health insurance system. ResultsThe revenue of CMOs derived from a risk-adjusted capitation. The capitation formula was weighted only by age and sex. The expenditures of the CMOs included all the health expenditures on their patients that occurred in any part of the health care system. The average savings rate for all CMOs for the fiscal years 1999 to 2007 was 4.94%. The highest rates of savings were realized in chronic and acute inpatient care and medical devices. The pilot was discontinued in 2008 without a comprehensive evaluation of the experience. ConclusionsWe can conclude that this pilot had a significant contribution to the modernization of the Hungarian health care system.

The history of the Read codes: the inaugural James Read Memorial Lecture 2011

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) recommended that the Read Codes be adopted nationally. The Read Codes have been used by almost all GPs in the UK since the mid-1990s. Many developments in general practice, including GP fundholding (where GPs held the budgets to commission elective care for their patients), the Quality and Outcomes Framework (QOF - pay for performance for improving chronic disease management) and GP commissioning (the current NHS reform in which primary care leads commissioning of services for their patients) would have been impossible without all GPs using a common clinical coding scheme. Systematized Nomenclature For Medicine - Clinical Terms (SNOMED CT) is a merger of the Read Codes with SNOMED RT - the original SNOMED reference terminology developed by the American College of Pathologists.

Lancet UK Policy Matters: better evidence for better health

Since its inception, the UK's National Health Service (NHS) has been repeatedly reorganised by successive governments, often at great cost and with little evidence of improved performance.1 The new coalition government recently published a white paper, followed by a Public Bill that, once again, proposes a radical overhaul of NHS structures.2,3 Certain features of these latest proposals for reform hold clear similarities with previous models of delivery, such as general practitioner (GP) fundholding, first introduced in the early 1990s by a Conservative government.

The management and development of hospital pharmacy in the new National Health Service in the UK

Abstract The introduction of an internal market in health care in the United Kingdom has created a structured relationship, defined by contracts, between health care providers, such as NHS hospitals, and purchasers, such as general practitioner fundholders. Similar relationships are developing within hospitals between clinical directorates and support service departments, such as pharmacy. A 1993/4 interview survey, conducted at eight hospitals, obtained the views of 129 pharmacy, nursing, medical and managerial staff on pharmacy service development and management in this new environment. Contracts between pharmacy and clinical directorates were in place in only two of the hospitals. Where contracts existed, pharmacy managers viewed them positively but they acknowledged the resultant managerial challenges. Most pharmacy managers at sites without contracts were threatened by the prospect of them. In contrast, non-pharmacy staff welcomed contracts as an opportunity to define their service requirements. For most managers of support services such as pharmacy, the implementation of the internal market will present challenges. Managers will need to become familiar with their customers' needs using information from several sources, including pharmacists working within directorates. Then efforts will have to be made to negotiate contracts that meet those needs while permitting the further development of staff and services.

General practitioner commissioning: dialogue is key

The health policies of the Coalition Government are becoming clearer, and it appears that a significant part of the future belongs to general practitioners (GPs). Many district nurses will remember GP fundholding, which had mixed effects. In some cases, GPs wanted to use their buying power to secure ‘their’ community nurses and health visitors; in others, they experimented with a developing provider market to buy in community services from organizations some distance away.

General Practitioner Commissioning in the English National Health Service: Continuity, Change, and Future Challenges

General practitioner fundholding (GPFH) in the English National Health Service was abolished by the Blair administration in 1999 amid concerns that it was inequitable, helped to foster a "two-tier" health service, and incurred high transaction costs. In April 2005 in an apparent volte face, the Blair government reintroduced delegated budgets to individual GP practices under the banner of Practice Based Commissioning (PBC). As PBC bears many similarities to GPFH it is timely to take stock of evidence-based policy lessons from the earlier initiative in the NHS. Based on a review of the latest empirical evidence, the aim of this article is to help inform the development and implementation of PBC by identifying the policy lessons of GPFH. To do this the discussion focuses on three main areas: it (1) reviews key ideas and conceptual frameworks for understanding stability and change in health systems; (2) summarizes the origins and evolution of primary care commissioning in the NHS; and (3) examines the latest literature and empirical analysis on the impact of GPFH and assesses the success of GPFH in meeting a range of health policy objectives. The article concludes with an examination of the policy implications of the present review and a look forward at the emerging research agenda.

Will Practice-Based Commissioning in the English NHS Resolve the Problems Experienced by GP Fundholding?

Labour's new approach to primary health care, based around the policy of practice-based commissioning, has considerable potential for learning from the general practitioner fundholding reforms put in place by the Conservative governments of the 1990s. However, practice-based commissioning seems to repeat many of the same problems as the earlier policy. Despite the increased scope for GPs to make a significant difference to the shape of local health economies because of the incentives and opportunities offered by payment by results and patient choice reforms, the potential problems of practice-based commissioning threaten the reform's viability and long-term success.

Homelessness and health: what can be done in general practice?

In England between January and March 2003, 31 470 households were newly accepted by local authorities as homeless.1 The large and increasing numbers of people so categorized have complex health, social and psychological needs, and in the past decade numerous centres have been established to provide primary care to homeless populations.2 Personal medical services legislation has made this possible; previously, the system of general practitioner (GP) fundholding was an obstacle to primary care for homeless people with complex problems.3 The new nationally enhanced GP contract will probably offer incentives for care of homeless people.4 What are the existing barriers for this group? In a report to the Office of the Deputy Prime Minister, they included surgery opening times, appointment procedures, location, financial disincentives and discrimination.5 Reasons for discrimination include perceptions that they are migrant, violent, antisocial or ‘undeserving’.6,7 Additionally, we contend that some homeless people face a further risk of exclusion because of their age, gender, ethnic background or sexual orientation. In primary care, challenging behaviour can be an issue, but categorization of an individual as ‘deserving’ or ‘undeserving’ takes no account of the societal factors such as unemployment and poverty that can lead to homelessness.8 The General Medical Council exhorts doctors not to allow personal views about patients' race, culture, gender, sexuality or age to prejudice the care they receive.9 This places a challenge to clinicians not to exclude people from healthcare on account of homelessness or possible drug-using culture. A comprehensive account of the management of the common health problems associated with homelessness is beyond the scope of this paper. Here we seek to describe the principles of best practice.

Coping with conflict and confusing agendas in multidisciplinary community mental health teams

This paper arises from a study, conducted in the final year of general practitioner fundholding in Britain, which was designed to explore the factors influencing client allocation within six community mental health teams in the north of England. It describes the strategies employed to manage the problems created by the disparity between the stated and agreed purpose of the teams and the actual pattern of referrals. A number of strategies were identified in the six teams to manage this fundamental conflict--isolation, homogenization, fraternization, negotiation and manipulation. A sixth strategy was designed to ameliorate the loss of professional identity experienced by those who were operating in a 'foreign' milieu--that of demarcation.

Financial incentives, competition and a two tier service: lessons from the UK National Health Service internal market

The experience of General medical practitioner (GP) fundholding is analysed for evidence of the response by family doctors to financial incentives. An analysis of consultant outreach, the local provision of out-patient services, in Scotland finds little evidence of a response, based on comparing the experience of fundholders with non-fundholders. At least in the case of hospital based services, financial incentives seem to be of secondary importance. Financial incentives for such services depend on consultant compliance which, arguably, was missing when it came to creating a two-tier service which deliberately favoured patients from fundholding practices.

Hospital competition, GP fundholders and waiting times in the UK internal market: the case of elective surgery.

In this paper I model the demand for and supply of elective surgery using a modified Hotelling framework in which time, money, and distance are determinants of the demand for hospital care. Hospitals compete with each other in terms of the waiting time and consequently treat a certain number of patients. The basic model of hospital competition is then extended to incorporate the general practitioner (GP) fundholding scheme whereby the GPs are allocated a budget with which to buy care for their patients. Waiting time increases when production of care becomes more expensive, when the benefit obtained from treatment increases, when the unit cost of distance decreases, and when the importance given to time as a performance indicator decreases. The higher the money price the lower the waiting time. Finally, the money price paid by the GP fundholders is greater than that paid by the Health Authorities and greater than the hospitals marginal cost of production. As a consequence, fundholding patients pay a zero time price while non-fundholding patients experiment a positive waiting time.

Catching waves: the historical geography of the general practice fundholding initiative in England and Wales

General practitioner fundholding is often represented as one of the more successful elements of the 1989/90 Conservative reforms of the UK National Health Service (NHS). Successive annual ‘waves’ of fundholding practices were approved from 1990 through to 1997 and, over time, the initiative came to involve some 50% of UK general practitioners. Fundholding is known to have had a strong regional geography that changed with evolving fundholding eligibility criteria. Further, there have been persistent allegations that fundholding tended to occur disproportionately in areas of higher social status. Past studies of fundholding have tended to consider single waves or the overall impact of the initiative rather than its development over time. They have also tended to work at a single geographic scale or through single-region case studies when exploring the statistical regularities underlying the uptake of fundholding. Using multilevel analysis, this paper seeks to enhance understanding of fundholding through an examination of the interaction of district health authority and practice characteristics across all implemented waves for all general medical practices in England and Wales. We conclude that wave mattered on a national scale, that deprivation was relatively unimportant and that there were certain types of area that exhibited persistent but unexpected high uptake.

Improving Secondary Care Efficiency: Motives and Mechanisms in Scotland

Improving the efficiency of the NHS has been a consistent policy objective of British governments in recent years and the structures and mechanisms appropriate for stimulating efficiencies have led to both radical and incremental changes. This article discusses the attitudes and behaviour of fundholding and non-fundholding general practitioners (GPs) under the market system, and uses this as a basis for proposing efficiency improvements within the new health service structures in Scotland.

An audit of current clinical practice in the management of osteoporosis in Nottingham.

Osteoporosis is now recognized by the World Health Organization and the Department of Health as a major public health problem. In 1994, the Advisory Group on Osteoporosis (AGO), set up by the Department of Health, recommended that Health Authorities and general practitioner fundholders should purchase bone densitometry services for the management of osteoporosis. The aims of this study were to assess the criteria for requests for bone densitometry from primary care in comparison with the AGO recommendations and to compare the numbers of patients referred with a low-trauma osteoporotic fracture with the expected number of fractures in the Nottingham area. Patient referral data and requests for bone densitometry were collected by case note review of all new patients referred to the Nottingham Osteoporosis Clinic over a 12 month period and then compared with the AGO recommendations. The patients referred with a history of a low-trauma fracture were then compared with the expected incidence of fractures, calculated using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics. A total of 413 patients were referred to the Osteoporosis Clinic for bone densitometry. Almost two-thirds of the patients had no clinical indicators for requests for scanning, in comparison with the AGO recommendations. Seventy-seven patients were referred with vertebral fracture, 12 hip, 20 colles and 26 other fractures. Using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics, it was estimated that the expected incidence of hip fractures would be 812, distal forearm fractures 514 and vertebral fractures presenting to clinical attention 625. This represents 1.5 per cent of the total hip fractures, 3.9 per cent distal forearm and 12.3 per cent vertebral actually presenting to the Osteoporosis Clinic. Bone densitometry was requested in up to 60 per cent of the patients with no clinical risk factors to warrant bone densitometry. Osteoporosis-related fractures remain unrecognized in clinical practice. The majority of patients do not receive specialist assessment despite being at high risk of future fracture. Further steps are necessary to educate health care professionals in primary and secondary care, but more importantly, to direct services more proactively in those at high risk of future fracture.

Improving standards for palliative care services in Northern Ireland.

Northern Ireland has a population of approximately 1.6 million people. Within the geographically small area there are many isolated rural communities. Since 1969, health and social services in Northern Ireland have been managed and delivered through an integrated health and social care system, unlike the rest of the United Kingdom (UK) where the two are administered separately. Health and social services are commissioned through four health and social service (HSS) boards, general practitioner (GP) fundholders and a number of pilot commissioning schemes, and services are provided through or by HSS trusts, voluntary agencies and the independent sector.

Health technology assessment in the United Kingdom.

The National Health Service (NHS) provides universal health coverage for all British citizens. Most services are free of charge, although modest copayments are sometimes applied. About 11% of the population also has private insurance. General practitioners, generally the first point of contact for accessing the system, are independent contractors who serve as gatekeepers for specialist and hospital services and enjoy substantial clinical autonomy. Hospitals are public and are regionalized, but the 1990 reforms made them self-governing trusts that contract with local purchasers (health authorities and general practitioner fundholders). Reforms beginning in 1990 moved the NHS away from a centralized administrative structure to more pluralistic arrangements in which competition, as well as management, influences how services develop. Health technology and health technology assessment (HTA) have gained increasing attention in the NHS during this period, as part of a wider NHS Research and Development (R&D) Strategy. The strategy promotes a knowledge-based health service with a strong research infrastructure and the capacity to critically review its own needs. HTA is the largest and most developed of the programs within the strategy. It has a formal system for setting assessment priorities involving widespread consultation within the NHS, and a National Co-ordinating Centre for Health Technology Assessment. The strategy supports related centers such as the U.K. Cochrane Centre and the NHS Centre for Reviews and Dissemination. A hallmark of the HTA program is strong public participation. The United Kingdom has made a major commitment to HTA and to seeking effective means of reviewing and disseminating evidence.

Commissioning mental health services: role of the consultant psychiatrist

The current National Health Service (NHS) approach to commissioning health services is in flux. The purchasing of care from providers by general practitioner fundholders (GPFHs) and health authorities has changed with the new White Papers. GPFHs no longer exist and the commissioning role is being handed over from health authorities to primary care groups (PCGs). An understanding of the reasons for change and current arrangements will aid the consultant psychiatrist in influencing this process.

A System for Determining the Priority of Referrals within a Multidisciplinary Community Mental Health Team

The high level of demand for community mental health services implies a need for allocating priority to referrals. Pressure to achieve this has been apparent in the British national health and social services since reorganisation in 1991. What has been less clear Is how this could be carried out within individual services. The project arose in response to increasing referrals to a local community mental health team from general practitioner fund holders, leading to unacceptable waiting times for clients. A questionnaire was sent to all 49 general practitioners serving the area, of whom 35 responded. The survey was designed to gain information about the factors influencing referral to the service and the levels of satisfaction with the intervention provided. The results highlighted an urgent need to reduce waiting times and to target clients with greatest need more effectively. This information led to the development of a system to assess priority of referral. The system, still in use, assesses five components: level of distress, level of functioning, suicidal intent, motivation and contact with other services. Scores are allocated to each section. An overall score determines the client's starting point on the waiting list. Additional points are accrued during waiting times ensuring that movement up the list is continuous.

The impact of a quasi-market on sexually transmitted disease services in the UK

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.