GP Fundholding Research Articles

How can GPs and community health services work more effectively together?

On 23 October 2014, NHS England Chief Executive Simon Stevens published a new 5-year plan for the NHS. Highlighting the challenges facing the NHS associated with an ageing population, the document argues: ‘The traditional divide between primary care, community services, and hospitals — largely unaltered since the birth of the NHS — is increasingly a barrier to the personalised and coordinated health services patients need .’1 It then goes on to discuss what models of care might look like under the plan. The focus is on integration and collaboration, eschewing further structural change but highlighting the potential of new service models which bring GPs together with a wide range of other providers, including community, social, and acute care services. Moving care closer to patients’ homes is highlighted, with vulnerable patients cared for proactively by multidisciplinary teams. None of this is new. GP fundholders pioneered better access to diagnostic tests and outreach by hospital consultants in the 1990s,2 while the 2000s brought Community Matrons, Virtual Wards, and Models of Case Management.3 However, integration between primary and community health services (CHS) has not been easy to achieve,4 and it is far from clear that such service models can, in fact, reduce costs.5 Against this background, an extensive review of existing literature was conducted to explore what factors should be taken into account in planning for primary care and CHS to work more effectively together. Starting with interdisciplinary healthcare teamworking (the micro-level), evidence was examined across all levels of the current care system to account for the diversity of the services. At the meso level (that is, …

Health System Reform in the United Kingdom

How to control the increasing health expenditures is a common problem in the developed countries. The main causes of this increase are ageing of the society and medical innovation. The UK government has introduced a market oriented health reform in order to balance the increasing expenditures and the quality of care. For example, they have introduced the GP Fundholding, Private Financial Initiative (PFI) for construction of public hospital, and personal budget system (a patient owns a budget for buying health services in the deregulated market). However, there is little evidence indicating the effectiveness of these programs. On the other hand, it is important to strengthen the labor policy in order to maintain the social security system. For example, programs for increasing the employment rate and those for increasing productivity work sharing are such policies. From this viewpoint, the EU countries have introduced a series of active employment policies, i.e., job training for unemployed persons and work sharing. Furthermore, as other authors report in other articles of this volume, the government of the UK has introduced the Fit for Work (FFW) program that intends to medically support workers.

Do NHS services have to be provided by the NHS?

After 18 months of political trench warfare over the health bill, the Westminster bandwagon is moving on. However, for the NHS, this is the beginning not the end. Leaders in the NHS need to make sense of the hand they have been dealt and start turning the Health and Social Care Act 2012 into a workable system that delivers better care for patients. At times like these, it is useful to look back on the past decade or so of policy-making in healthcare – in the NHS and further afield. A constant issue that governments have faced has been finding a balance between centralisation and localism. Advocates of centralism stress and place value on ‘the need to standardise’ and emphasise ‘equitable access’. Meanwhile, advocates of localism prize the importance of ‘clinical freedom’ and ‘encouraging innovation’. Behind such ideas lies a recurrent, fundamental and often unhelpfully polemical debate about the best way to ensure that equitable, high-quality healthcare is available to all of a country’s citizens rather than an elite few, with no wide gulf in citizens’ quality of care. It is therefore well worth reflecting on the way policy makers and senior leaders in the UK have responded to the question over the past 15 years to see what that tells us about the future. To begin, one should recognise the ideological factors in play; for example, people in the UK fundamentally believe that access to healthcare is a universal right and have strongly supported this principle since the inception of the NHS. However, in recent years, the policy development of using choice and competition to move from a universally available, average system to a higher quality, more-personalised and individually tailored system has begun to challenge these fundamental assumptions. In light of this, the issue of centralism versus localism has often and misleadingly equated the centralist view with a predominant desire for equity, while the non-centralist view has been equated to a less-managed, deregulated world in which a market philosophy sits more comfortably. This has led to decentralisation policy becoming a political question and, unhelpfully, has turned what should have been an evidence-based debate about policy into a hotly contested political debate. In 1997, the incoming Labour government did not hesitate to declare its preference on the spectrum, moving immediately to centralise and standardise the offer for patients. It abolished the previous Conservative government’s flagship GP fundholding programme, which was perceived to be highly partial and, after eight rounds of applications, had only just managed to cover more than 50% of the nation. The Labour government put in place primary care trusts to commission services with universal coverage, the National Institute for Health and Clinical Excellence (NICE) to standardise decision making on treatment, and performance-managed national targets. Interestingly, there was an opportunity to decentralise in 2000 when the Labour government set out the NHS plan – a ‘national framework within which they could have encouraged local freedom’ – and backed this with a huge increase in resources. However, the desire of ministers to account for the use of these resources to improve waiting times led to centralised performance management – not empowerment of frontline organisations. In their defence, policy makers of that time might point to the creation of foundation trusts, arguing that the decentralisation of power was focused on provider side policy rather than commissioning. However, many – including some former ministers – would say that the aspirations to liberate foundation trusts to act as real local agents were frustrated – first by political concessions and then by an overzealous regulatory regime. To this day, many foundation trusts question the notion of having thousands of members as part of their governance arrangements. A second big opportunity for decentralisation came three or four years later. The NHS was performing well against central targets, with dramatic reductions in waiting times across the country, new money was coming on stream and understanding

Health System Reform in the United Kingdom

How to control the increasing health expenditures is a common problem in the developed countries. The main causes of this increase are ageing of the society and medical innovation. The UK government has introduced a market oriented health reform in order to balance the increasing expenditures and the quality of care. For example, they have introduced the GP Fundholding, Private Financial Initiative (PFI) for construction of public hospital, and personal budget system (a patient owns a budget for buying health services in the deregulated market). However, there is little evidence indicating the effectiveness of these programs. On the other hand, it is important to strengthen the labor policy in order to maintain the social security system. For example, programs for increasing the employment rate and those for increasing productivity work sharing are such policies. From this viewpoint, the EU countries have introduced a series of active employment policies, i.e., job training for unemployed persons and work sharing. Furthermore, as other authors report in other articles of this volume, the government of the UK has introduced the Fit for Work (FFW) program that intends to medically support workers.

The end of the NHS?

‘What do you call a man who ignores medical advice? Mr Clarke’.1 It is more than 20 years since the BMA tried to rally public opinion against Ken Clarke, then Mrs Thatcher's health minister, pushing through plans to introduce the internal market, hospital trusts and GP fundholding. The BMA's pompous ‘doctor knows best’ slogan was a spectacular flop and the Conservatives' market reforms were imposed on a divided medical profession and a largely indifferent electorate. Although the public lacked much enthusiasm for the reforms, people were also fed up with being patronised by doctors and taken for granted by public sector …

Preliminary findings from an economic analysis of nurse prescribing

Abstract A study was carried out to examine the economic and qualitative aspects of nurse prescribing for patients, carers, nurses and other health care professionals. The design was a case study, without controls or randomisation, and involved patients, nurses, general practitioners and other health care professionals in GP fundholding practices, one in each region of England, that were designated by the Department of Health as demonstration sites for nurse prescribing. This paper reports the data from the economic analysis. The main outcome measures were changes in the frequency and cost of prescribing compared with a range of scenarios, and the impact on health professionals' time. There was no evidence to suggest that prescribing costs in the eight demonstration sites increased more than they would have done in the absence of nurse prescribing. It is relatively safe to conclude that the impact on prescribing costs in those sites was neutral. The range of uncertainty around the first-year costs in the demonstration sites is nevertheless high, in the order of £240,000. Further work is required to identify the economic impact of nurse prescribing with a larger sample of practices, to assess whether prescribing costs will be contained (preferably in relation to a control sample) and whether notional time savings are cash-releasing. Research is also needed to shed light on questions of appropriateness and effectiveness of prescribing.

The biggest debate since the NHS was founded

New leaders are advised to implement major change at the start of their term in power. Andrew Lansley, the new secretary of state for health, is certainly playing from the management consultant's script. Health experts have described the Con–Lib coalition's proposals for health as the most dramatic restructuring of our health service since the NHS was founded. When the new health white paper revealed that primary care trusts would be scrapped and budgets controlled by GP consortia, shockwaves were created by the extent of the proposals not the nature of them. Indeed, this is not new thinking to readers familiar with GP fundholding. Clinician leadership has been a mantra of Conservative health policy in opposition. As has a preference for quality outcomes focused on clinical indicators rather than process measures. Yet the early GP fundholding experiments were inconclusive and a limited roll out. We now have a blanket national policy that many clinicians will view as simply another redisorganization of the NHS. In theory, clinical leadership is to be encouraged. Clinicians are eminently capable of acquiring the necessary strategic, management, and financial skills to control budgets and resources. A proportion of clinicians, the entrepreneurs and frustrated businessmen, will embrace this dramatic reform. Others will be ambivalent, unsure how it will affect them and how they might cope. The remainder will be unhappy that their focus might be diverted from clinical care; a career in medicine was supposed to be about managing patients not budgets. But whichever category clinicians fit into, they will require support. You might have the inclination but you probably won't have the time to delve into the finer dealings of your consortium. You might not even have the inclination. Medical school barely prepares doctors to treat patients; it certainly isn't any preparation for running a multimillion pound budget. If the first question is who will support clinicians in running the new world, the second is who will provide them with the appropriate information to make sensible decisions about the population that they are responsible for? Private companies will be queuing up to provide solutions with huge pound – and dollar – signs in their hungry eyes. The world has also changed for hospital specialists. Will the new system make them disempowered service providers to their colleagues in primary care? We want to hear your views. The editorial and essay pages of the JRSM are ideal channels for this explosive debate – the biggest healthcare debate since the inception of the NHS.

Health care deprivation profiles in the measurement of inequality and inequity: An application to GP fundholding in the English NHS

This paper proposes a new approach to the measurement of inequality and inequity in the delivery of health care based on contributions from the literature on poverty and deprivation. This approach has some appealing characteristics: (1) inequity is additively decomposable by population subgroups; (2) the approach does not rely on socio-economic ranks; (3) it provides a graphical representation of the distribution of inequity; (4) it offers a range of indices consistent with dominance. An empirical application is provided investigating the effect of the GP fundholding reform on equity in English NHS. The results show that the most equitable GP practices self-selected into the scheme in 1991; evidence of an inequity-reducing treatment effect as well as a self-selection effect are found in 1992 and 1993; the self-selection process reduces and no evidence of a treatment effect is present thereafter.

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.

Models for quality improvement and assurance in English and Welsh primary care

Background: Various initiatives have been tried to improve the quality of primary care in England and Wales in the last fifteen years. Such initiatives can be divided into quality improvement (QI) and quality assurance (QA). Purpose: This paper looks at three contrasting models, drawn from data from 48 semistructured interviews with personnel from three primary care organisations (PCOs): two primary care trusts in England and one Local Health Board in Wales. Findings: The first model was collegiate, a voluntary doctor-led initiative begun during the period of GP fundholding. The second is clinical governance, a current government-imposed system administered by PCO officers, which has attracted limited engagement from GPs. The third is the Quality and Outcomes Framework of the new GP contract, which was generally described positively, although the process of administering it was experienced as bureaucratic. Discussion: The three models correspond with three organisational types: networks (which use peer relationships to achieve goals), hierarchy (which use ‘top-down’ requirements and monitoring) and market (which use contracts). Although doctors have traditionally preferred network-style arrangements, the success of these arrangements in sustained QA and QI has been questionable. The importance of hierarchical arrangements is inevitable, given the functions and constitution of PCOs, and the risk that GPs will disengage is similarly inevitable. However, it is important that PCO officers find ways to engage GPs as much as possible in quality initiatives if patient services are to improve.

Performance pay remuneration for consultants in the NHS: is the current system fair and fit for purpose?

How to reward doctors for performance over and above their basic responsibilities has always been contentious. George Bernard Shaw1 recognized that the profit motive and doctors' entrepreneurialism create the wrong incentives for good medical practice and it is taken for granted that the professional ethic requires doctors to place the needs of the patient above all else. Any suggestion that extra financial rewards be given for the clinical care they deliver raises possible conflicts of interest because it becomes more difficult to determine if doctors are sacrificing patients' needs to financial expediency. Yet most doctors who practise in the developed world are part of organizational systems in which pay is linked to ‘merit’ and to some form of performance appraisal. Of course, in the medical field, pay is rarely linked directly to clinical performance but it is frequently contingent on clinically related fields—for example, rational prescribing, meeting waiting list targets and taking management decisions which may impact directly on patient care. In UK general practice it is not unusual for doctors who meet their prescribing budgets to be financially rewarded by keeping the savings. During the early 1990s, when GP fund-holding was being promoted, many benefited directly from savings made to clinical budgets. In the hospital sector the existence of discretionary awards and distinction awards can be considered as a form of performance-related pay (PRP) and it is in this context that this paper discusses the issue of pay for performance. This paper examines the development of the NHS merit pay scheme, reviews the operation of the merit pay schemes with particular reference to the issues of discrimination, and discusses the PRP scheme and whether such schemes are appropriate for rewarding individuals in health-care systems where teamwork is becoming increasingly important.

Practice-based commissioning has many hurdles to overcome

Practice-based commissioning (career development March 29) has been tried before – it was called GP fundholding.

The wisdom lost in knowledge: changes in the face of general practice

The wisdom lost in knowledge: changes in the face of general practice

Changing times and a fresh start for BJCN

We all know that these are times of great change. The last decade (and probably the decade before that) has seen an unending succession of Acts, White Papers, guidelines and directives. GP fundholding has come and gone. Primary care groups have been replaced by primary care trusts. Nurse prescribing has become part of the nursing landscape. The emphasis in primary care is increasingly on prevention rather than cure, on maintaining people at home rather than rushing them off to the hospital.

The Enlightenment of the NHS

Modernising the NHS is a difficult process, and it's arguable that nobody has ever tried it before. Yes, there have been reforms, reviews, and restructurings, from the Griffiths Report to the internal market and GP fundholding. Yet the ambition and proposed scale of the current reforms outstrip these prior attempts.

Primary care budget holding in the United Kingdom National Health Service: learning from a decade of health service reform.

1. The United Kingdom National Health Service (NHS) has experienced 10 years of primary care budget holding in a variety of forms. 2. Half of all general practitioners had joined the GP fundholding scheme by 1997, and many others had joined broader GP commissioning groups, but fundholders controlled only about 20% of the budget for hospital and community health services. 3. Research on fundholding and commissioning groups suggests that delegation of budgets produced some gains in the range and effectiveness of services, but also had significant management costs and inequities. 4. From 1999, all primary care professionals joined Primary Care Groups, which are now becoming Primary Care Trusts (PCTs). PCTs will control three-quarters of the healthcare budget and provide all primary and community services as well as commissioning hospital care. 5. Control of a unified healthcare budget presents opportunities to improve quality, increase integration of services, reduce inequities and improve health. However, PCTs are threatened by a growing gap between capacity and expectations, and by continuing tension between devolution of power and increasingly prescriptive management by central government.

Waiting times for hospital admissions: the impact of GP fundholding

Waiting times for hospital care are a significant issue in the UK National Health Service (NHS). The reforms of the health service in 1990 gave a subset of family doctors (GP fundholders) both the ability to choose the hospital where their patients were treated and the means to pay for some services. One of the key factors influencing family doctors’ choice of hospital was patient waiting time. However, without cash inducements, hospitals would get no direct reward from giving shorter waiting times to a subset of patients. Using a unique dataset, we investigate whether GP fundholders were able to secure shorter waiting times for their patients, whether they were able to do so in cases where they had no financial rewards to offer hospitals, and whether the impact of fundholding spilled over into shorter waiting times for all patients.

Organisational resistance strategies to unwanted accounting and finance changes

This paper explores the resistance strategies of organisations to unwanted changes. It is concerned with the way satellite organisations are created to provide a counter force to environmental disturbances such as changes introduced in the context of what has come to be called New Public Management. Its particular focus is with the attempt to develop and institutionalize external, “public” forms of resistance rather than undertake more internal, “private” forms. The specific empirical focus is general medical practice in the UK, where commissioning groups were formed as an alternative to GP fundholding. To help analyse this empirical detail we draw insights from Habermas’s model of society, organisational change theory and institutional theory. In the process the paper not only amplifies the empirical reactions of GP practices in the UK but also uses this empirical detail to develop the nature of this theoretical base by adding new dimensions concerning organisational resistance.

A socio-legal and economic analysis of contracting in the NHS internal market using a case study of contracting for district nursing

The introduction of an internal market in the National Health Service (NHS) in the United Kingdom necessitated the use of contracts between purchasers and providers. Little thought was given to the nature of these contracts by policy makers, who appeared to assume that the contracts could conform to the classical, complete model. This paper uses socio-legal and economic theories of contract (which provide an alternative model of relational contracts, in contrast to classical contracts) to explore how realistic that assumption was. An analysis of the institutional context in which the contracts were made is provided, including a legal analysis of the relevant legislation. Contracting by health authorities and GP fundholders is examined, using the results of a recent case study of contracting for district nursing services carried out in a health authority in Greater London. The results show that classical contracting is an inappropriate model for NHS contracts, but that relational contracting is not an entirely appropriate model either. Contracting was found to have increased the accountability of providers in respect of some financial matters, but not in respect of the quality of district nursing services. There are negative implications for the use of contracting in publicly financed health services—hierarchies may be more efficient (as lower transaction costs can be incurred) and possibly more effective in improving quality of care.

Policy and Place: General Medical Practice in the UK

Introduction The Development of General Practice: From Potions to Purchasing Promoting Better Health Gatekeeping and Beyond: GP Fundholding and Commissioning Models Accounting for their Actions: Regulation and the GP Practices and Patients Practices in Context: Urban and Rural General Practice GPs and their Patients: Relationships Defined by Profession and Policy General Practice, Health and Social Care: Histories and Challenges Conclusion: Comparisons and Futures Bibliography Index