Review

Budgets for all by the year 2000

Purchaser plurality in UK health care
Nicholas Mays and Jennifer Dixon
King’s Fund, 1996
A review of innovations in primary health care
Lyn Harrison and Hilary Neve
The Policy Press, 1996, £14.95

After years of proclaiming its unique role at the heart of health care, primary care has suddenly, and rather uncomfortably, found itself at the centre of everyone’s attention. For better or worse, the phrase ‘primary care-led NHS’ is on everybody’s lips and the battle to turn the words into various contested future forms of organisation is well underway.

The debate comes at a time of rapid and confused change for primary care in general and general practice in particular, as the latter continues its uncertain transformation from simple ‘gatekeeper’ to sophisticated ‘purchaser’ of care. Yet the form and content of this new function are by no means fixed. Indeed, the debate over the pros and cons of different future arrangements for general practice have become so intense as to emerge as a significant pre-election issue.

Mays and Dixon have entered the fray with a slim volume which aims, and succeeds, in bringing clarity to the current noisy confusion. They begin by setting out a very helpful description and taxonomy of the various flavours of purchasing organisation currently in existence, including HAs, GP commissioning, locality commissioning, total purchasing pilots, standard and community fundholding, multifunds and extended fundholding schemes. This is just the thing to help those who wish they knew what everyone else pretends to know already.

A discussion of the likely success of these approaches in meeting the key aims of a public health service – such as practicality, user involvement, maintaining equity and minimising transaction costs – then follows.

The glimpse of the future which their very considered analysis offers is a disturbing one. It rapidly becomes clear that many approaches will ultimately converge of a future form of NHS organisation characterised by multiple purchasers pursuing diverse agendas within a complex regulatory regime, which becomes ever more complex in an attempt to hold everything together.

The parallels with the US experience of deregulation in the 1980s, with spiralling costs, growing bureaucracy and increasing potential for perverse behaviour, are clear and provide a stark contrast to the relative simplicity of the pre-reform NHS. In the future, 1,000 budgets will bloom – but nobody will want to hear you scream.

Harrison and Neve’s brief but substantial review of practical projects in primary care comes as a welcome relief to this vision of market-driven madness. This similarly slim publication presents a loosely organised array of projects and pilot schemes in primary care settings, with a paragraph of information on each.

Although the material included seems somewhat arbitrary, there is enough here – from teledermatology to nurse triage, from advocacy to occupational health – to spark off ideas in even the most jaded NHS professional. While the practical emphasis of this review, with its lists and contact addresses, seems a long way from the high-level policy debates of Mays and Dixon, there are connections.

For example, there are projects testing out new roles for community pharmacists — one of the aspirations of the recent primary care white papers. And if, or when, primary care fragments and diversifies, there will be increasing demand for new ways to share good practice. Perhaps the next edition should be on the internet.