Primary care in England

Discuss the changes that have occurred in primary care in England during the last 10 years. What has been the impact on patients? How might developments in general practice continue over the next 10 years? Philippa Callegari General Practice is a well-used and valued public service. Eight out of ten people visit their general practitioner (GP) every year 1 and 99% of the English population are registered with a GP. The service costs i?? 8. 2 billion (including prescribed drugs), which is one fifth of the NHS total expense. 2

The main development in health care policy has been the introduction of market mechanisms within the NHS 3. This move was the initiative of the Conservative Party and aimed at giving the Primary Health Care Team (PHCT) more say over the delivery of secondary care. Its purpose was to increase efficiency and limit increases in expenditure. The development of general practice (GP) fundholding which began to appear in 1989 4, was also part of this plan to have the NHS run from a primary care outlook and was articulated as such in 1994 5.

As a result of increasing demands and rising costs in the early 1990’s, the Conservative government split the NHS up into providers (i. e. hospitals) and purchasers (i. e. local health authorities and some fundholders) 4. The government encourages this development as GP fundholding lowered prescribing costs. By 1998, over half of the English population was covered by some form of fundholding arrangement. However, there was much concern amongst GPs at some aspects of the fundholding scheme.

It was felt that if they were responsible for “buying” services for their patients from their budgets, then their position as a clinical advocate for individual patients would be compromised 6. Once the Labour government was elected, many people thought it would bring to an end to fundholding and pay GPs to take on locality commissioning, but it didn’t. The 1997 White Paper for England asserts that, “decisions about how best to use resources for patient care are best made by those who treat patients.

7” As a result, the number of managers in health authorities has diminished and been replaced by members of the PHCT in Primary Care Groups (PCGs). These groups now involve all GPs (unlike fundholding which just included GPs who chose join in). Thus around 500 PCGs, each covering populations of around 100,000, took over from nearly 4000 current organisations such as local health authorities and fundholders, to become Primary Care Trusts (PCTs). A trust has the responsibility to develop and commission local health services in line with the health improvement programme 8.

PCTs are local and autonomous organisations and have control of up to 80% of the local health budget. They are run by committees, having as many as nine health professionals (including up to five GPs) from a total of 13 members. Other members include community consultants and health professionals allied to medicine, such as physiotherapists, nurses or occupational therapists, as well as some members of the public. PCTs however do not have the purchasing power of single large health authorities and as a result, have limited annual prescribing budgets for providing medical services and developing primary care 9.

Since 2001, changes in primary care have continued unhindered. There have been changes in the way funds are allocated across the PCTs, the overall level of funding has increased, and there are also plans to introduce a new General Medical Services contract that puts more emphasis on performance related pay and quality incentives. Recent policy changes will have a great effect on general practice; this change in allocation of funds for the PCTs will mean that money for their practice will follow the needs of the patients, instead of investment decisions for the doctors.

The new GP contract recommends more flexibility in the workload for individual practices and gives greater emphasis to quality. Practices have also made other changes in recent years; these include out of hours services, with many GPs forming groups to share the responsibility between practices. Another advance is the growth of large practices. The number of GPs working in practices with six or more GP partners has grown from 1 in 5 practices in 1988, to 1 in 3 in 2001 2.

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