Primary care: choice and opportunityBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7064.1026 (Published 26 October 1996) Cite this as: BMJ 1996;313:1026
Letting a thousand flowers bloom to promote the primary care led NHS
Last week saw the launch by the British government of yet another white paper on primary care1 as a prelude to another new law. Those in the front line of the health service can be forgiven for reflex alarm; we seem to have been here before. But this time seems to be genuinely different. This white paper comes after the “listening process”2 and distils ideas presented to the Department of Health and the NHS Executive by professionals on the ground. And for the first time it is not them telling us that ‘mother knows best’. It is more a confession that rigidities have been imposed in the past that have inhibited our capacity to function effectively.
In essence Choice and Opportunity creates the capability for the NHS to sanction and evaluate experiments in primary care that are designed to improve both sides of the cost-effectiveness equation. General practices can choose to continue as at present. But those who find that current contracts and regulations inhibit the changes they want to make, will be helped and even encouraged to test their ideas. In theory this should unleash general practitioners' imaginations and exploit their innate capacity for innovation, creating a market place of ideas and excellence through evolution and diversity. However, the history of health service reforms argues for caution, and there are caveats that must be heeded if this white paper is to attain its lofty objectives.
The antagonism generated by the 1990 contract3 was not predominantly due to its content—although some of this was and is contentious—but to the way it was imposed on general practitioners. The subsequent establishment of fundholding, even though voluntary, still proved divisive because of perceived inequalities of funding opportunity and care. But fundholding can be seen as a paradigm for the innovations that the new legislation will encourage, and it is reasonable to consider what lessons can be learnt from the experience.
Firstly, as a global scheme fundholding has shown few efficiency savings, largely due to high transaction and management costs.4 Future innovations should be able to be self funding, except for the cost of their evaluation, with any cost of setting up the innovation being balanced by efficiency savings. But this of course is only possible if there is sufficient slack in the system. If there is not, innovation will only flourish if the NHS as a whole receives more funding. Secondly, despite the lack of efficiency savings, leading fundholders have improved patient care,4 and it is this that should be the main criterion for judging the success of future initiatives.
But the real lesson from fundholding seems to me to be that the levers have been too indirect, and the usual unit size (a single general practice) has been too small (and thus the availability of skills to low and management costs too high). In Christchurch, New Zealand, a group of 200 general practitioners have been commissioning primary and now secondary care services using real money and redeploying real savings,5 without direct financial benefit to the doctors (such as the use of savings for new buildings as happens in Britain). Locality commissioning has been advocated here6 and might, given real financial control, offer a useful model for evaluation under the new white paper's proposals.
Every change carries risks and benefits, and this is no exception. There is a clear commitment that practices wishing to continue under the present arrangements can do so, but many will feel that they should follow local colleagues into local experiments. The clearest risks are the integration of General Medical Services, and thus general practitioner earnings, into commissioning, and the erosion of the purchaser-provider split. I will take these in turn.
This white paper describes the possibility of practice based contracts. In these a whole practice team will negotiate a contract for providing primary care services for patients on their list and will be monitored against an agreed range of services and quality of care markers. While liberating the practice from most regulations and encouraging practices to explore new skill mixes and cost effective ways of delivering services, any underfunding would put the partners' income at risk (and surpluses in the fund could lead to excessive income). Such a scheme would move us towards a “salary”—in the sense of a predicted, ring fenced income—even if not quite to the salaried option for individual doctors that is also described in the white paper.
The second potential problem lies in a confusion of the general practitioners' purchasing and providing roles. One strength of fundholding has been the capacity of the general practice purchaser to raise expectations of the hospital trust providers. But what is sauce for the goose is sauce for the gander, and the quality divide in primary care brings the need to empower purchasers—at present the health authorities—as they enter into local contracts with providers, the general practices. While local general practitioner contracts that extend or replace the national contract will be possible under this legislation, the white paper also presents the option of a total fund held by practices that covers primary and secondary care. The more practices become the purchasers of their own primary care the more difficult will it be for the health service to maintain accountability. On the other hand, it could be said that it is high time that we reconsider general practitioners' independent contractor status and the nature of medical partnership in the light of team based care; and one pre-condition of any innovation could be increased accountability for the quality of primary care.
If this white paper becomes law, the whole NHS—practices, community teams, health authorities, and trusts—is in for a cultural shift explicitly designed to further empower and resource primary care. For many of us in general practice the prospect is tantalising, but the knock on effects will be profound. By using pilots and evaluation, ill effects should be minimised and the pace of change should be contained. But there are bound to be losers. Primary care is being given real power. It must use it responsibly by working with others and keeping the goal of better patient care throughout all sectors of the health service clearly in sight.