Feature

Today’s docs are buying it all

Even if you don’t like fundholding, there’s a lot to be said for total purchasing, says Uli Freudenstein

In total purchasing, budgets cover all care, including emergency and maternity care. Fundholding budgets pay only for elective care, outpatient and community care, drugs and staff. Locality commissioning leaves health authorities in charge of all budgets but offers family doctors more involvement in commissioning.

Total purchasing is more than just an extension of fundholding. As the weaknesses of fundholding became more obvious (high management costs, two-tier service, fragmentation of planning) it developed as an alternative. And it has started in the way that fundholding should have done. Four pilot projects were prepared from 1993 onwards. There are now 50 pilot sites with accompanying evaluation. The latter may be funded at only £5,000 per site and only cover two years but at least it is being done at all.

From the government’s point of view, total purchasing tries to preserve the involvement of primary care in purchasing with less destabilisation to the NHS as a whole. Labour is likely to support this move. It fits perfectly with the proposed policies of abandoning fundholding and supporting other forms of joint commissioning of which total purchasing would be one.

Funding will be similar to non-fundholding. The scale of the projects may mean extra set-up costs but siphoning off savings into individual practices on a large scale will become a thing of the past. Health authorities and the government hope that groups of practices involved in total purchasing will put pressure on each other to conform to agreed policies (something that has not happened with non-fundholders and fundholders).

Total purchasing pilot sites are larger than the average fundholding practice. There will therefore be fewer purchasers. Fundholders, at least in some parts of the country, have accounted for proportionately more emergency admissions than would have been expected. Responsibility for total budgets would put an immediate stop to that. Where more than one practice is involved, co-operation between practices will have to increase.

Bizarrely the government insists that all participants in total purchasing also become fundholders. This means all participating practices have to write separate business plans and accounts for fundholding too. Such insistence appears to be entirely politically motivated, because all total purchasing pilot sites can then be counted as fundholders.

A wide variety of projects have sprung up, offering greater involvement to GPs in planning health services. This has become known as locality commissioning. Participation is voluntary so a complete consensus is not needed before changes are implemented. Consequently, some HAs and many GPs continue to carry on very much as before. Total purchasing, in contrast, motivates all practices to take part in policy making.

Earlier this year GPs in Sheffield discussed their willingness to consider total purchasing, community fundholding and locality purchasing. A majority felt that all options meant more bureaucracy. They saw no sign that such an increase was worth the effort. Admittedly the worst case scenario of any of the available options must be an increase in administration without any resulting improvement for either patients or health workers.

But despite the widespread scepticism of my colleagues I can see much good in total purchasing. Practices will receive more resources, more training and so get a great deal more out of participation.

Total purchasing pilots can abolish the barrier between primary and secondary care funding. This will mean a gradual shift of resources to primary care as workload transfers into the community. Fundholding did not achieve that.

Total purchasing pilots will be in a better position to reorganise care after hospital discharge and the care of old and very old patients outside hospital. This would reduce the number of hospital beds needed and make seamless community care feasible.

The transition will not be easy. Providers will not wish to part with resources. GPs will not be keen on an increased workload.

If the projects are to succeed, calls for smaller list sizes, more staff and better organisation of out-of-hours care will have to be heeded. The work patterns of GPs will alter. The way they are currently paid is likely to change in the process. More technical skills among primary care workers will be needed.

Total purchasing pilots can adjust primary care funding to the realities of minimally invasive treatments, short hospital stays and an increasingly elderly population. As things stand there is no sign that either locality purchasing or fundholding will produce similar opportunities.