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Feature Health policy

The market in primary care

BMJ 2007; 335 doi: (Published 06 September 2007) Cite this as: BMJ 2007;335:475
  1. Allyson M Pollock, professor1,
  2. David Price, senior research fellow1,
  3. Elke Viebrock, lecturer1,
  4. Emma Miller, research fellow1,
  5. Graham Watt, professor2
  1. 1Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG
  2. 2Department of General Practice, University of Glasgow, Glasgow
  1. Correspondence to: A M Pollock allyson.pollock{at}

    Changes to primary care have shifted clinical control away from general practitioners and financial control away from government, argue Allyson Pollock and colleagues

    Since 2003 the government has created a market in primary care and replaced the old general medical services contract governing general practitioners with a range of alternatives. The changes gave primary care trusts in England, health boards in Scotland, and local health boards in Wales new powers to negotiate contracts with commercial companies.1 2 Many of the changes to regulation were intended to facilitate the entrance of new providers to the healthcare market.3 General practitioners are no longer contracted directly to the NHS but to the firms or practices that contract with primary care trusts in the market. These bodies are in turn regulated largely through the market mechanism of commercial contracting. We explain how the reforms change the basis of government control and mechanisms for public accountability in primary care and the possible effects on staff and patients.

    Breaking the monopoly

    The primary care market is premised on the break-up of the general practitioners' monopoly of the provision of primary care. From 1948 until 1997 GPs were contracted to work for the NHS under a general medical services contract between the secretary of state and the individual practitioner, on terms negotiated nationally. The contract was set out in the provisions of the RedBook, an extensive set of guidelines and regulations covering range and quality of services, staffing, and premises.

    The national contract was broken in 1997 by the introduction of personal medical services contracts, which allowed local negotiations between general practitioners and commissioners about service specification.4 In 2003 the Health and Social Care (Community Health and Standards) Act ended the general practitioners' monopoly over the provision of primary care to the NHS, allowing primary …

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