Column
News from nowhere
Before the last election word went out from the Department of Health to the NHS command structure ‘not to rock the boat.’ Sudden change upsets people and makes bad news, which no government wants.
But this time they either do not care and have given up, or they have been so successful at devolving responsibility for health services to local agencies that they no longer have any leverage on the rate of change. The NHS boat is not so much rocking as pitching and heaving, in plain view of the public. Two stories illustrate its erratic motion.
The first is a shire counties tale, reported in the Health Service Journal (11 July 1996). A small community based trust in Andover, faced with ruin because of shrinking health authority funding, is thinking of dissolving itself into yet another type of structure, a combined fundholder-community services outfit based around a cottage hospital. The community trust would bring £8m income and five fundholding practices would add another £17m to create a hybrid ‘purchaser-provider’, not unlike an American Health Maintenance Organisation.
One mechanism for achieving this merger would be a private finance buy-out of the trust, spearheaded by the fundholders in a big breakthrough for the mixed economy of health care. Health minister Gerald Malone is reported as saying: ‘I hope others around the country follow the example of Andover’.
The second story comes on the grapevine from Newcastle, where a community trust has ‘recruited’ a group practice, incorporating the doctors on a salaried basis and managing the practice from trust resources in return for the practice income. This ‘buy out’ of an inner city practice is exactly the opposite of the Andover story, and may be the shape of things to come for urban general practitioners who do not want to go down the HMO path.
The integration of general practice into the NHS is long overdue, but there is a world of difference in these two routes to integration. The Andover approach may be hugely popular in the town itself, but it will reconstruct the local health service around the priorities of general practitioners, and will introduce all the risks that HMOs carry with them — like redefining patient needs according to budgets — without there being any competition to sharpen decision making.
The Newcastle approach brings GPs into a provider team with other professionals, avoids confusing their tasks with purchaser responsibilities, and is both logical and equitable. healthmatters hopes that others around the country will follow the example of Newcastle, not Andover.
