Purchasing for all: an alternative to fundholding

Introduction

General practitioners have always had opinions on the quality of the hospital care their patients receive. Around 5% of consultations lead to a referral,1 and patients often want to discuss the options available or to report their experiences after seeing a specialist. Until the NHS and Community Care Act 1990 split the NHS into purchasers and providers2 general practitioners who wanted to question the quality of the secondary care their patients received, or the priorities set by local hospitals, had to negotiate largely on the hospital's terms. Since the reforms, however, the commissioning process has offered an alternative way to influence secondary care.

Though fundholders may have more influence on the hospital care covered by their budgets, their small size and the fact that the district health authority still purchases most of their patients' care means they too can have an interest in the decisions the district health authority makes. To purchase effectively, district health authorities need to know what is happening in the health service locally, and as a result many have come to see general practitioners as a source of information and advice. It is this recognition of a common interest between general practitioners, demanding better secondary care for their patients, and health authorities, seeking grassroots feedback, which has led to a range of schemes to involve general practitioners in health care commissioning.*RF 3-6* The way this has developed in different areas has been influenced by the extent of fundholding, the ability of general practitioners to coordinate their approach, and the commitment of the district health authority.7 Some district health authorities have developed a genuine partnership with general practice whereas others have been more reluctant to share decisions.

In City and Hackney most general practitioner participation in commissioning has been through a “general practitioners' forum.” This paper evaluates the approach the forum has taken.

Hackney general practitioners' forum

The general practitioners' forum was established in 1985 with support from the department of general practice at St Bartholomew's Medical College and has become a focus for discussion about health services locally. All City and Hackney general practitioners are invited to the monthly meetings, which rotate from surgery to surgery to encourage more to attend. When the NHS reforms were introduced the forum adopted a twin track approach, trying to win influence through the district health authority but considering a fundholding consortium if this was not achieved. In the event only two practices chose to become fundholders.

The first links with the district health authority entailed setting up advisory groups, which helped draft the first contract with the local provider but then lapsed.8 By 1992 it was apparent that a more coordinated approach was needed if general practitioners were to participate effectively, so the family health services authority agreed to fund an administrator and (together with the district health authority) seven sessional purchasing adviser posts. These general practitioner advisers have met monthly as a core group, but each has established his or her own links with particular specialties. These links include attending joint planning meetings, work on clinical guidelines, audits, and educational activities, all of which have helped the advisers establish a clearer picture of the current services and how they could be improved.

Method

The minutes of 28 forum meetings from December 1989 to June 1993 were analysed to provide attendance rates and details of the main issues discussed. The minutes of two further meetings were not available. The issues reported were grouped into categories and used to design a questionnaire, which was then piloted and sent to all general practitioners in City and Hackney. The doctors were asked how important they considered these issues were as well as how representative and effective they thought the forum was. Two reminders were sent. Details of doctors' qualifications were taken from the medical list of the family health services authority.9

Additionally, 33 senior NHS managers who either headed departments at the family health services authority, district health authority, or local provider or chaired joint planning groups were asked their views on how representative and effective the forum was. The SPSS/PC+ package10 was used to analyse the results, with X(super2) tests to assess the response rate and attendance at meetings and non-parametric tests for the questionnaire results.

Finally, the 1993-4 contract between City and Hackney Health Authority and the St Bartholomew's NHS Trust11 was analysed to see how many of the new items were contributed by or had significant input from general practice. The attribution of these was confirmed, item by item, with the general practitioners concerned and the health authority contracts manager who wrote the document.

Results

Ninety nine (76%) of the 131 general practitioners and 27 (82%) of the 33 health service managers responded. General practitioners who failed to respond were significantly less likely to have attended any forum meetings (X(super2) = 19.9, df=1, P<0.001). There were no significant differences in practice size, year of registration, and qualifications between those who did and did not respond.

Discussion

The supporters of fundholding have claimed it “offers an opportunity to make the health service responsive to general practitioners, acting on behalf of patients,”15 but many fear it will lead to a two tier health service, waste a great deal of money on administration, and allow rationing decisions to undermine the doctor-patient relationship.16 Do “commissioning partnerships” between general practitioners and health authorities offer the benefits but not the risks of fundholding?

This study has shown that most general practitioners in Hackney feel well represented by the general practitioners' forum and that managers respect it as a representative body. However, it points to the need to draw in more local doctors and to improve links with the two fundholding practices.

Though most of the managers were impressed by the forum's effectiveness, a quarter of the general practitioners had doubts about the extent of their influence. In part, this reflects the way that the health service agenda in London has been dominated by the Tomlinson report and the provider changes which have followed. As a result, developing purchasing and ensuring quality of care have at times seemed to have a lower priority. This is best illustrated by the dilemma about whether to impose financial penalties on a local hospital for failing to meet targets, when the real issue is whether the hospital will survive at all.

Fundholding at present concentrates mainly on a limited range of elective work, but the general practitioners' forum has been able to influence a wider range of services. For example, it is questionable whether mental health services would have been given such a high priority had most local practices opted for fundholding. The isolation of fundholding practices may also limit their ability to achieve strategic changes in the pattern of service delivery, whereas by working with the district health authority general practitioners may be able to achieve this.

This study also highlights the need to review the relation between general practice and public health medicine. As Hannay has pointed out,17 we are both concerned in health promotion; we are both concerned in purchasing. Though nationally the two branches of the profession may have lost touch, locally our links have been productive. The public health department has concentrated more on health and health promotion, as well as researching the efficacy of treatments like tonsillectomy. General practitioners have brought their generalist's knowledge of the health service and incorporated this into the detail of contracts. They can monitor performance, by auditing the care their patients receive, and at times be a voice for others who cannot talk freely in today's NHS, an approach illustrated by the forum's public campaign in response to the Tomlinson report.

If general practice is to have an increasing role in purchasing, schemes like this will need political commitment from the Department of Health. Those involved will need training, administrative help, and funding for time spent on purchasing. General practitioners need to work closely to develop a consensus if they want to be listened to and, similarly, health authorities must be prepared to share important decisions and offer representation at every level if a commissioning partnership is to be based on trust.

This model has developed in an area where the general practitioners' forum already provided a voice for general practice. It is seen as both effective and representative, and this review documents the influence the forum has had on services locally. In other areas general practitioners may take different approaches, but the opportunity to help commission more responsive services is there for all.

We thank the general practitioners and health service managers who completed the questionnaires; Chris McManus for statistical advice; Clare Goodhart, Gabby Tobias, and Gene Feder for commenting on the manuscript; and Nick Evans for checking the attribution of changes to the contract with the Barts NHS Trust.