GP Fundholding (Hansard, 21 February 1996)

§ Lord James Douglas-Hamilton

The findings of the project were reported as follows:

"SUMMARY OF CONCLUSIONS"

In relation to prescribing

1. Both holding a fund and being subject to the constraints of an indicative prescribing budget are associated with a reduced volume of prescribing;
2. fund-holders may be more cautious than non fund-holders in introducing new and more expensive preparations to their repertoire. (This is not itself necessarily a 'quality' issue);
3. the quality of prescribing has been maintained in that prescribing volume has risen in three clinical areas where this has been generally recommended by consensus thinking; and
4. budgets should be set on a per capita rather than on an historical basis, and that research aiming to identify what that per capita basis should be needs to be based on more sensitive measures of volume (for example 'DDD's') and not simply on formulae derived from 'prescribed-items.'

In relation to referral

5. Fund-holding has been associated with a significant change in the pattern of use of hospital services; the downward trend in most areas of activity has been matched by an upward trend in the use of direct access services;
6. the changes in waiting time and outcome have not been dramatic but are generally favourable; and
7. development of the process of setting capitation-based allocations will be difficult.

In relation to clinical care

8. The clinical care of patients at consultations has remained generally stable; however,
9. patients in some groups have done well in relation to others when consultation length and enablement are considered together. These include patients with angina, diabetes, chronic bronchitis and difficulties with seeing. They have in common that they are low prevalence problems, are associated with lower levels of social problems, affect older patients and (in the case of diabetes, angina and chronic bronchitis) belong to categories whose care has been subject to 'new contact' incentives.'
10. Patients in the other eight clinical groups (we studied) have done less well in relation to the above in that they report falling enablement and generally higher levels of increase in social morbidity. In the three most prevalent categories (pain, skin disorders, digestive problems) the falls in satisfaction have reached statistical significance;
11. patients with social problems which they wish to discuss have done well (receiving generally longer consultations and reporting sustained and average levels of satisfaction); and
12. patients with social problems they do not state they wish to discuss and who have high GHQ scores receive only average length consultations and report low enablement while those with low GHQ scores receive below average length consultations but report average enablement. Both these groups could be regarded as having done less well than others. Each is more prevalent than all but four of the clinical categories we studied.

In relation to administration

13. The process of negotiating the nature of specialist care between practitioners and specialists has been novel, has shifted ownership of care significantly and appropriately from secondary to primary care, and has been conceptually beneficial to general practitioners and patients; and
14. that further thought needs to be given to the evolution of fund-setting both for the prescribing and hospital services components of funds.

About perceptions of cost and benefit

15. Patients are generally very satisfied with the quality of the services they receive from general practitioners and the level of satisfaction has been maintained over the period in the fund-holding practices we studied and;
16. being the 'lead' doctors in a fund-holding practice has time and perhaps other costs which are higher than those experienced by other doctors. Their perceptions of benefits are also higher. Fund managers perceive higher costs than benefits. Non-lead doctors perceive both costs and benefits at a lower level than do the other groups.

Amongst respondents from fund-holding practices in March 1994

17. Sixty two per cent. are positive or very positive about fund-holding, 24 per cent. are neutral and 15 per cent. are negative; and more generally;
18. the concept of centrally funded evaluative work by independent researchers has been a strength of the 'shadow' experiment; it has worked acceptably (probably on both sides), and it could be a repeatable model in the future.

We finally conclude

19. That discussion of the possible benefits which might follow if the investments in management and in information technology given to fund-holders were also given to non fund-holders should be encouraged".