The white paper spells evolution not revolution
- Jennife Dixon, Fellow in policy analysisa,
- Nicholas Mays, Director of health services researcha
- a King's Fund, London W1M 0AN
Since May the new Labour government has repeatedly pledged to abolish the reforms of the NHS carried out by the previous Conservative government in 1991. The internal market, competition, the business ethic, and general practitioner fundholding would be swept away and bureaucracy and inequities in access to care reduced. But with no new big idea to hand akin to the radical changes of 1991, and with an awareness that not all the reforms were bad after all,1 2 this government had a problem. Should it believe its own rhetoric and reverse most of the changes, as promised, without anything new to replace them? Or should it swallow its pride, concede that some features of the internal market were worth keeping, and build on the best?
The result, published last week in the white paper, The New NHS,3 is, of course, a compromise. The rhetoric is that the internal market, which supposedly resulted in damaging competition, has been abolished. In reality, competition was weak, the purchaser-provider split will remain, and purchasers will still have some choice between providers. So what's new?
Quite a lot. The main change concerns primary care. The chief responsibility for purchasing health care will move from the current 100 health authorities, 3600 fundholders, and 90 total purchasing pilots to 500 primary care groups each covering “natural communities” of roughly 100 000 people. Primary care groups are to consist of groups of general practitioners (around 50) and community nurses which will eventually hold a budget for virtually all hospital and community health services for the area plus the cash limited part of the general medical services budget—for example, for prescriptions and practice staffing. Health authorities will continue to purchase only selected specialist services, and fundholding will be scrapped from April 1999. The plan is for …