Editorials

A primary care market?

It is a fact universally acknowledged that primary care is one of the great strengths of the British health care system. The NHS reforms initiated by Margaret Thatcher in 1989 have shifted the balance of power towards primary care and resulted in more services being provided by general practitioners and colleagues in primary care. This in turn has led to the emergence of new kinds of primary care organisation. These include fundholding practices, multifunds, total purchasing projects, commissioning groups, and out of hours cooperatives. The formation of these organisations is beginning to break down professional isolation among general practitioners and is creating opportunities for greater collaboration. Paradoxically, it is also opening up the prospect of increased competition between primary care providers.

Of particular importance in this context is the establishment of unified health authorities in England and Wales in April 1996 and the responsibility given to these health authorities to promote the government's policy of a primary care led NHS. There is already evidence that those heading the new authorities are keen to move beyond the traditional model of general practitioners working through partnerships to deliver a standard range of general medical services. For example, some authorities have negotiated agreements with practices to offer a wider range of services and have diverted money from hospital and community health services budgets for this purpose.¹

At the same time, other authorities have encouraged the setting up of total purchasing pilots in which fundholders take responsibility for buying the full range of services for patients. In the case of the Bromsgrove total purchasing project, for example, this includes establishing a "hospital at home" scheme, increasing the use of a general practitioner ward at a community hospital, and contracting for the use of nursing home beds instead of using acute hospitals to provide respite care for patients (C Heath, personal communication).

NHS trusts are also promoting innovations in primary care. The City Health NHS Trust in Newcastle is employing general practitioners to provide general medical services on a salaried basis and is managing their practice staff. Elsewhere, many community trusts are working closely with general practitioners to integrate more effectively the work of primary care teams with that of staff such as district nurses and health visitors. Acute services trusts are also trying to be more responsive to the needs of general practitioners, such as by offering to provide specialist outreach clinics in their surgeries. As this happens, integration between primary care and community health services staff is developing in parallel with specialisation as general practitioners are encouraged to offer services in fields where they have particular expertise. An example is the Birmingham Multifund, in which general practitioners with specialist skills and training receive referrals from their colleagues as an alternative to hospital referral (G Corser, personal communication).

These initiatives show how collaboration between general practitioners is developing in parallel with competition to provide services. Yet if competition is to develop further, there must be a move away from the current national contract for general practitioners to greater discretion on the part of health authorities to negotiate agreements at a local level. The agreements between health authorities and general practitioners for the latter to provide services beyond those covered by the national general medical services contract indicate the shape of things to come. Extending this approach to part or all of the general medical services could quite rapidly stimulate a market in primary care as general practitioner partnerships, NHS trusts, and the new primary care organisations compete to win business from health authorities. There is every prospect of this happening in the light of the government's consultation document on the future of primary care,² which signals support for local flexibility in the provision of primary care services.

Increased competition could also occur if the government accepts the BMA's argument that the core of the general medical services contract should be defined more clearly. This raises the possibility of providers other than general practitioners entering the market to deliver non-core services. In effect general practitioners would become specialists in family medicine and much greater reliance would be placed on other staff (including general practitioner assistants) to carry out work that is currently the responsibility of general practitioners. This outcome may not be the one envisaged by the medical profession but it has obvious attractions to politicians concerned to squeeze ever increasing efficiency out of limited health care budgets.

The potential benefits of a primary care market are greater choice for patients and increased responsiveness to their needs. There may also be gains in efficiency. These could arise through competing general practitioner based delivery systems or from the substitution of nurses for doctors where this is appropriate. Quality of care may rise too as new entrants to the market stimulate existing providers to improve their performance and as innovative approaches are adopted to tackling low standards of service provision in deprived areas. But a major risk is that transaction costs will increase as local contracting replaces national negotiation. There is also a danger that competition will set doctor against doctor and make it difficult to build a culture of cooperation and collaboration and to break down professional isolation still further. And at a time when policy makers seem increasingly disillusioned with experience of market oriented reforms,³ any attempt to promote competition in primary care should be viewed with caution. All of this suggests that localised contracts and the primary care market need to be thought through carefully. At a minimum, they should be accompanied by evaluation to ensure that the effects are properly assessed and that policy making is evidence based.⁴

Director Health Services Management Centre, University of Birmingham

Chris Ham 

1. Meads G, ed. Future options for general practice. Oxford: Radcliffe Medical Press, 1996.
2. NHS Executive. Primary care: the future. Leeds: Department of Health, 1996.
3. Ham C. Contestability: a middle path for health care. BMJ 1996;312:70-1. [Free Full Text]
4. Ham C, Hunter DJ, Robinson R. Evidence based policymaking. BMJ 1995;310:71-2. [Free Full Text]