The UK health reforms: The fundholding experiment

doi:10.1016/0168-8510(93)90056-U

Health Policy

Volume 23, Issue 3, March 1993, Pages 179-191

https://doi.org/10.1016/0168-8510(93)90056-U Get rights and content

Abstract

In April 1991 the UK embarked on the most radical reforms of its health care system in 50 years. Unusually it employed two quite distinct models of quasi market reform. One made District Health Authorities the purchasers of hospital and community health services. The other gave family doctors the money to buy these services on behalf of their patients. This latter model was the most radical part of the NHS reforms. This paper reports on a project that has monitored the family doctor fundholding scheme in detail.

References (19)

A. Enthoven
Reflections on the management of the NHS
(1985)
G. Teeling-Smith
Should GPs hold the purse strings?
Health and Social Service Journal
(1985 24 October)
A. Maynard
Performance incentives in general practice, Health, Education and General Practice
(1986)
J. Weiner et al.
GP Budget Holding in the UK: Lessons from America
H.S. Luft et al.
Patient selection in a competitive health system
Health Affairs
(1988)
Department of Health
Working for Patients
H. Glennerster et al.
A Foothold for Fundbolding
(1992)
A. Coulter et al.
GP referrals to hospital
(1991)
P. Day et al.
Variations in budgets of fundholding practices
British Medical Journal
(1991)

There are more references available in the full text version of this article.

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The UK health reforms: The fundholding experiment

Abstract

Reflections on the management of the NHS

Should GPs hold the purse strings?

Health and Social Service Journal

Performance incentives in general practice, Health, Education and General Practice

GP Budget Holding in the UK: Lessons from America

Patient selection in a competitive health system

Health Affairs

Working for Patients

A Foothold for Fundbolding

GP referrals to hospital

Variations in budgets of fundholding practices

British Medical Journal