Voluntary for general practitioners, compulsory for health authorities

Ever since the inception of general practice fundholding in 1991 ministers have insisted that it is a voluntary scheme. This approach has resulted in a rapid expansion of fundholding: the proportion of England's population covered by the scheme increased from 7% in 1991-2 to 40% in 1995-6. Population coverage varies widely among districts, however, ranging from 4% to 87% in England in 1994-5.

The announcement last October of an extension to the fundholding scheme marks a further phase in its development.1 Health ministers clearly think that fundholding is a success and are treating it as the jewel in the crown of the NHS reforms. Independent commentators are more sceptical, arguing that no comparison has been made of fundholding and non-fundholding practices and calling for research into the effects of different models of commissioning health care.2

Ministers have gone some way towards heeding this call in deciding that total purchasing by fundholders (purchasing of all health care including maternity, accident and emergency, and medical and psychiatric inpatient services) will be evaluated. It will be compared, however, with the standard, more limited type of fundholding and not with approaches based on commissioning by health authorities. As a result, the government has missed an opportunity to establish the costs as well as the benefits of alternative approaches.

This lack of comparative research reflects the government's view of fundholding as the preferred model of purchasing. Despite assurances …