Does practice based commissioning avoid the problems of fundholding?BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39022.486921.94 (Published 30 November 2006) Cite this as: BMJ 2006;333:1168
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Greener and Mannion give an excellent commentary on the probable difficulties which will arise from practice based commissioning and compare them with the early experiments with general practice fundholding (1).
Our evaluation of the Scottish shadow fundholding project in the early 1990s is still the only study of commissioning/fundholding to have examined the effect of internal markets on individual patients consulting with the ordinary everyday problems which affect the majority of patients for the most part of their lives.
Our time series of cross sectional studies between 1990 and 1993 took in a period when social disadvantage in the community increased substantially, and with that the proportion of consulting patients with a combination of physical and psychococial problems increased in tandem. Although this made for difficulty in interpreting the reslts of our work, it gave us an unusual opportunity to comment on the care of disadvantaged groups of patients.
Unsurprisingly we found (as have others quoted by Greener and Mannion) that patients with 'incentivised' areas of clinical need benefited. But we also found that those with high prevalence disorders (particularly pain and musculoskeletal problems, and alimentary and dermatological problems)for whom social disadvantage increased most, had poorer outcomes than before market forces entered the political arena (2).
There is accumulating evidence that those with 'complex' problems(physical symptoms combined with psychosocial problems) benefit from seeing a familiar doctor, and need more than average time at consultations (3). The recent health service reforms in primary care are already compromising many of what were seen as the strengths of general practice of the pre-budget holding era (most particularly the provision of 'personal, primary and continuing care to individuals, families and a practice population....' which was the then definition of the good general practitioner (4)). We must sincerely hope that forthcoming attempts to increas efficiency and effectiveness in primary care - desirable as they are - will not continue to disadvantage those patients with most to gain from the best of primary care.
1. Greener I, Mannion R. Does practice based commissioning avoid the problems of fundholding? BMJ 2006;333:1168-70.(2 December.)
2. Howie JGR, Heaney DJ, Maxwell M. Care of patients with selected health problems in shadow fundholding practices in Scotland in 1990 and 1992. Brit J Gen Pract 1995;45:121-6.
3. Howie JGR, Heaney DJ, Maxwell M, et al. Qualuty at general practice consultations: cross-sectional study. BMJ 1999;319:738-43.
4. 'The general practitioner in Europe'. Working party appointed by the Second European Conference on the Teaching of General Practice, Leeuwenhorst, Netherlands, 1974.
Competing interests: None declared
Competing interests: No competing interests