Reforming British primary care (again)

It's hard to know what the changes will mean for patient care

Editorials p 748, General practice p 772, Education and debate p 797, Letters p 803

On 1 April all general practitioners in England and Wales will have to start working collaboratively in large local groups to commission and, in some cases, purchase secondary care for the populations they serve. 1 2 To general practitioners and many others in the NHS this is hardly hot news: they have been preparing for this shift since early last year. But, given that the NHS, and primary care in particular, has changed its structure so many times in the past decade, we thought that some BMJ readers could do with a little explanation.

In the early 1990s the Conservative government tried to contain increasing demand and rising costs in the NHS by splitting the service into provider trusts (hospitals and community and mental health services) and purchasers (health authorities and some general practitioners, called fundholders).3 Because general practitioner fundholding lowered prescribing costs, the government encouraged the model to develop and spread. By 1998 about 55% of the English population was covered by some kind of fundholding arrangement (these varied in the amount of secondary and community services that general practitioners purchased independently of health authorities).

Fundholding had many detractors. They argued that allowing only some general practitioners to buy and so influence their patients' care was inequitable. Thus many general practitioners who opposed fundholding but wanted to help shape secondary care teamed up to advise health authorities, unpaid, through locality commissioning. Many people expected the new Labour government to abolish fundholding and pay general practitioners to take on locality commissioning. But, in England and Wales at least, the government is now getting rid of both models and making commissioning mandatory for all general practitioners. General practitioners there will commission all secondary care except mental health services (which are too politically sensitive to hand over).

In England around 500 primary care groups, each covering populations of around 100 000, will take over from nearly 4000 current organisations—health authorities, fundholders, and locality commissioning groups. Each group will operate at one of four levels of complexity and influence, culminating in a primary care trust. At all levels these groups will have limited annual prescribing budgets and ring fenced funds (based on weighted capitation) for providing general medical services and developing primary care (pp 772 and 776). 4 5 General practitioners will run the boards of primary care groups with help from nurses, other primary care staff, and representatives from local authorities and the public (p 783).6 Health authorities will retain some control through local health improvement programmes, which primary care groups will have to follow when planning for provision and commissioning.

In Wales the reforms are very similar, but general practitioners' organisations will be called local health groups. As in England, the groups will have to work closely with local authorities, but this should prove easier in Wales because health and local authorities have served the same populations within shared boundaries since 1996.

In Northern Ireland, where health and social services have been integrated for the past 25 years, the government is still thinking about the best way forward for primary care. The province looks set, however, to follow England and Wales in April 2000 by abolishing fundholding and giving general practitioners a unified limited budget to collaborate and commission.7

The biggest diversion from the overall plan for primary care will happen in Scotland at the end of this month, when all forms of general practitioner commissioning will end.8 This, says the government, is because commissioning has proved so unpopular: fundholding has covered less than 20% of the population in Scotland. From 1 April all care outside hospitals will be run and paid for by primary care trusts comprising community and mental health providers and some general practitioners. General practitioners may choose to advise primary care trusts on commissioning through groups called local healthcare cooperatives. Cooperatives will be paid the previous fundholding management allowance and will have limited budgets for prescribing and providing general medical services.

Will all this change make things better for patients? Whatever happens, the new primary care organisations will have to do a lot better than fundholders. Even the most sophisticated form of fundholding, total purchasing, has had little effect on clinical outcomes, the shape of secondary care, or overall costs.9 One the other hand, total purchasing had barely an opportunity to make its mark before being swept away in the current round of reorganisation. At least this time the government has promised a long term programme, so that primary care groups (and their equivalents in other parts of the United Kingdom) can have time to settle down and a chance to make an impact on patient care.