General Practice

Reluctance of general practitioners to become fundholders

BMJ 1995; 311 doi: (Published 15 July 1995) Cite this as: BMJ 1995;311:166
  1. Ray Robinson, directora,
  2. Philippa Hayter, visiting research fellowa
  1. aInstitute for Health Policy Studies, University of Southampton, Southampton, Hampshire SO17 1BJ
  1. Correspondence to: Professor Robinson.
  • Accepted 13 April 1995

The reasons why general practitioners have chosen to become fundholders have been the subject of detailed research.12 In contrast, little systematic attention has been paid to the reasons why most general practitioners have chosen not to apply for fundholding. We conducted a series of in depth interviews to identify the attitudinal and organisational factors that had led a sample of general practitioners and practice managers to decide against applying for fundholding.

Subjects, methods, and results

A sample of 19 practices known not to be contemplating applying for fundholding was selected from within the South and West Regional Health Authority. Practices were chosen to reflect a range of characteristics, including variations in the extent of fundholding in their areas. In 17 of the practices we interviewed the senior partner, one other partner, and the practice manager. In the two other practices we were able to interview only one partner and the practice manager. Thus the final sample comprised 36 general practitioners and 19 practice managers. The interviews took place between 8 September and 10 November 1994.

An objection to fundholding on philosophical grounds was cited most often by both general practitioners and practice managers as the reason why their practice had decided not to apply for fundholding. Twenty four general practitioners stated clear or strong objections on these grounds (table). Dislike of the two tier system that was believed to result from fundholding and unhappiness about general practitioners' greater responsibility for rationing care with fundholding were the main reasons mentioned for holding these philosophical objections.

Numbers (percentages) of general practitioners and practice managers objecting to fundholding on grounds of principle, politics, or ideology

View this table:

A practical objection to fundholding because of its extra workload and time commitment was the second most commonly cited reason for not applying. This was mentioned by 27 general practitioners and 10 practice managers. Moreover, only nine general practitioners believed that their practice currently had the management capacity to cope with fundholding. Meetings with other general practitioners emerged as an important means of transmitting experiences and opinions about fundholding. The medical literature was also an important source of information. Training events, workshops, and conferences were less influential. Health authority policy seemed to be an important factor in influencing attitudes towards fundholding for many general practitioners. Several general practitioners reported that they were satisfied with the way that their authority purchased services on their behalf and saw no reason to change. Several different models of practice sensitive purchasing had been developed throughout the region as options to fundholding.3 In view of the government's plans for extending fundholding,4 we investigated some factors that might be expected to cause the sample practices to review their positions. Fifteen general practitioners said that if other practices in their locality started to become fundholders they would have to apply. Another 10 general practitioners said that this would “possibly” lead them to apply. In addition, both a management agency with the responsibility for managing their fund and a consortium arrangement with other practices were reported as mechanisms likely to increase the likelihood of applying for fundholding.


Developing NHS Purchasing and GP Fundholding clarifies the government's desire for a major expansion in fundholding.4 The scheme will, however, remain voluntary. As such, the success of the government's policy will depend on its ability to attract new recruits. Our results indicate that opposition to fundholding on grounds of principle among non-fundholders is extensive and strongly felt. This opposition is not, however, necessarily an obstacle to the recruitment of new practices. Over 40% of general practitioners said that if other practices in the locality started to become fundholders they would have to apply. Another 30% said that such developments would “possibly” lead them to apply for fundholding. These findings suggest that peer pressure and pragmatism are strong among general practitioners and are likely to be important determinants of how fundholding develops.


  • Funding South and West Regional Health Authority.

  • Conflict of interest None.


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