Editorial

Why the doctors don’t know best

If there is one thing worse than the arrogance of managers or politicians, it is the arrogance of doctors. And it has nowhere been better demonstrated than at the recent annual conference of the National Association of Fundholding Practices.

‘We will not accept shadow budgets or budgets controlled elsewhere’, thundered the fundholders’ leader, Rhidian Morris. ‘We do not want to be forced into groups but wish to choose who we work with.’ And the politicians—from all parties—could only shift uncomfortably and talk of ‘evolution’ and ‘sensible change’.

But who are these doctors who would, with astonishing arrogance and not a little self-interest, dictate the future of the NHS? This is the section of the medical profession which has never been fully a part of the NHS, refusing to sign up to the new scheme in 1948 and preferring instead to remain as ‘independent contractors’ ever since. And these are the doctors who, in a rich historical irony, have had ‘their mouths stuffed with gold’ through the fundholding policy, but still remain semi-detached from the NHS, wanting more. Far from binding them more fully into the structures of the health service, the government’s largesse has given them the idea that they can determine the provision of health care while themselves remaining independent of it, unmanaged and unaccountable.

And for what reason? Where is the evidence for the ‘great success’ of fundholding, as health ministers and fundholding leaders would have us believe? In fact, such evidence as exists shows a very limited return from a considerable investment of public money. It is not clear whether the apparent gains—better control of prescribing costs and reduction in referral to secondary care—are the result of fundholding or other influences on the early adopters of the scheme, nor whether they have benefited patients. What is quite clear is that the management and transaction costs of GP purchasers are much higher than those of health authority purchasers, making any claims that fundholding represents an increase in overall efficiency look very dubious indeed.

Further, any improvements that there may have been in fundholding practices—and there have been some—have been bought at a high cost in terms of equity and accountability, which the fundholders would prefer that we conveniently ignored. Yet there are fundamental questions here which have not received satisfactory answers.

The system provides incentives both for fundholders to avoid expensive patients and to shift costs to other purchasers (such as private insurers, or to the health authority by having patients attend A&E departments), and for providers to treat fundholders’ patients preferentially, leading to longer waits for others. Do such abuses occur? We do not know, but given that financial incentives are known to be a powerful influence on clinical behaviour, and off-the-record confirmation is not unknown, the concern must remain.

The unaccountable and costly nature of the fundholding experiment suggests that it will be only a transitional stage in the evolution of the NHS into a more fully-fledged market system. But what will replace it? Many are putting their bets on total purchasing projects, which aggregate fundholders into groups large enough to make the overheads and financial risks manageable, while drawing the GPs into the accountability framework which follows from ‘performance management’ by the health authority.

Some will welcome such a ‘total purchasing’ future as the embodiment of a primary care-led NHS, a GP-run mini-health authority. But look deeper into the crystal ball, and you’ll see the emergence of competition between purchasers for patients—but not sick ones. Neither fundholding nor total purchasing are the way to go.