The response of GP fundholders and practice managers to the reorganisation of primary care services
| Published date | 01 July 1998 |
| Date | 01 July 1998 |
| Author | Duncan Goldie,James W. Sheffield,Paul Coleshill |
| DOI | 10.1177/095207679801300306 |
| Subject Matter | Articles |
The
response
of
GP
fundholders
and
practice
managers
to
the
reorganisation
of
primary
care
services
Paul
Coleshill,
Duncan
Goldie
and
James
W.
Sheffield
University
of
Paisley
Aims
This
article
aims
to
answer
a
number
of
linked
questions.
The
first
involved
a
detailed
recording
of
management
behaviour
and
management
skills
as
demonstrated
within
the
General
Practitioner
Fundholding
(GPFH)
practice.
The
purpose
for
doing
this
was
to
determine
whether
or
not
GPFHs
had
acquired
management
skills,
and
whether
or
not
these
skills
had
been
used
to
benefit
primary
care.
If
GPFHs
demonstrated
such
skills,
the
second
objective
was
to
determine
the
use
to
which
these
skills
would
be
put
in
the
proposed
reorganisation
of
primary
care.
In
order
to
do
this,
we
examined
the
proposed
structure
of
primary
care
in
Scotland,
and
asked
GPFHs
about
the
consultation
process
and
their
role
in
the
proposed
structure.
Introduction
Background
to
GP
Fundholding
Scheme
GP
fundholding
was
introduced
as
a
part
of
the
NHS
and
Community
Care
Act
(1990).
GP
fundholding
was
an
integral
part
of
changes
occurring
throughout
the
NHS
at
this
time,
designed
to
create
an
internal
market.
The
reforms
were
based
on
an
ideology
which
assumed
that
an
internal
market
for
healthcare
would
create
administrative
efficiencies
and
also
result
in
a
more
effective
allocation
of
resources
(Enthoven,
1985,
HM
Government,
Department
of
Health
1989).
These
reforms
have
been
extensively
reported
and
many
of
the
debates
surrounding
the
reorganisations
can
be
found
in
'A
future for
the
NHS?'
(Ranade,
1995).
GP
fundholders
(GPFHs),
were
intended
to
act
as
purchasers
and
providers
of
services
within
this
internal
market.
Instead
of
using
a
referral
system
dependent
on
the
Health
Authority
or
Board
within
which
they
practised,
the
GPFH
had
a
devolved
budget
and
acted
as
an
agent
for
his/her
patients
in
terms
of
purchasing
secondary
care.
In
effect,
they
were
given
control
over
their
referrals
allowing
them
to
choose
the
best
value
contract
for
their
patients.
Public
Policy
and
Administration
Volume
13
No.
3
Autumn
199870
Pilot
schemes
commenced
in
England
and
Wales
in
1991
and
Scotland
in
1992.
The
main
difference
for
the
distinction
between
Scotland
and
England
and
Wales,
was
that
Health
in
England
and
Wales
was
overseen
by
the
Department
of
Health
and
Social
Security,
whilst
in
Scotland,
Health
was
a
department
within
the
Scottish
Office.
Due
to
the
separate
legislative
framework
that
operates
within
Scotland,
government
circulars
are
often
rewritten
to
suit
Scottish
needs.
In
addition
to
this,
the
Health
Service
in
Scotland
had
a
different
organisational
structure,
and
many
would
argue
a
unique
organisational
culture.
Numerous
reports
and
papers
have
recorded
the
GP
fundholding
scheme
in
both
Scotland
and
England
and
Wales
(Lapsley,
Llewellyn
and
Grant
1997;
Ellwood,
1997;
Farmer,
1998;
Fischbacher
and
Francis,
1998;
Strong
and
Hammer-Lloyd,
1997).
As
reported
by
Lapsley,
Llewellyn
and
Grant
(1997),
fundholding
grew
at
a
slower
rate
in
Scotland,
mainly
due
to
the
criteria
set
down
by
the
NHS
guidelines.
These
specified
a
certain
minimum
size
for
a
practice
in
order
to
allow
it
to
become
fundholding.
Few
of
the
Scottish
practices
could
meet
the
early
patient
register
threshold,
and
as
a
result
of
this,
the
scheme
had
a
slow
start.
In
addition
to
this,
and
not
mentioned
in
the
other
studies,
fundholding
operated
in
a
distinctly
different
way
in
Scotland.
As
a
result
of
the
differences
in
government
circular
timing,
and
the
slow
uptake
of
the
scheme
in
Scotland,
differences
in
administration
arose.
For
example,
reports
of
audit
concern
regarding
some
GPFHs
bank
accounts
in
England
and
Wales
allowed
the
Scottish
National
Health
Service
to
devise
a
slightly
different
way
of
adminis-
tering
the
scheme.
The
Health
Board
retained
fundholding
accounts
and
adminis-
tered
the
account
for
the
GPFH.
In
England
and
Wales,
GPFHs
had
been
given
a
sum
of
money
to
operate
through
a
bank
account.
Retention
of
the
account
by
the
Health
Board
in
Scotland
meant
that
Scottish
GPs
had
to
submit
monthly
returns
and
invoices
to
prove
the
volume
of
referrals
and
prescriptions
flowing
through
the
practice.
In
England
and
Wales,
this
financial
probity
was
left
to
external
audit
and
a
year
end
check.
Aims
of
the
GP
Fundholding
Scheme
The
scheme
aimed
to
devolve
decision
making
to
the
level
of
the
General
Practi-
tioner.
GPFHs
were
to
have
the
discretion
to
seek
the
best
medical
care
for
their
patients
at
a
cost
they
felt
appropriate
to
treat
the
illness.
GPFHs
were
given
a
budget
based
on
historic
data
(although
it
was
assumed
that
at
some
point
a
capitation
formula
would
replace
it).
The
two
main
determinants
of
the
budget
were
the
prescribing
element
(drugs
and
medicines)
and
the
referral
element
(secondary
treatment).
By
switching
to
generic
prescriptions
and
monitoring
value
for
money
when
referring
patients
to
competing
NHS
trusts,
(Farmer,
1998;
Strong
and
Hanmer-Lloyd,
1997),
GPFHs
could
achieve
savings.
This
devolved
decision
making
was
a
feature
of
the
new
public
management
school
espoused
by
Osborne
and
Gaebler
(1992).
More
specifically,
it
could
be
described
as
a
particular
type
of
action
new
to
public
managers.
This
'entrepreneurial'
activity
was
a
fundamental
assumption
in
the
Austrian
School
Public
Policy
and
Administration
Volume
13
No.
3
Autumn
1998
71
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