OBJECTIVE--To compare prescribing patterns between a group of fundholding practices and a group of non-fundholding practices in north east Scotland using a method which provides more accurate statements about volumes prescribed than standard NHS statistics. DESIGN--The pharmacy practice division of the National Health Service in Scotland provided data for selected British National Formulary sections over two years. Each prescription issued was converted using the World Health Organisation "defined daily dose" mechanism. SETTING--Six fundholding groups (nine practices) in Grampian and Tayside regions and six non-fundholding practices in Grampian. RESULTS--During the past two years both fundholding and control practices reduced the volume of their prescribing for the classes of drug analysed. The unit costs of drugs in some classes, however, rose substantially, contributing to higher costs per patient. The unit costs rose more in the control practices (24%) than in the fundholding practices (11% in Tayside, 16% in Grampian). CONCLUSION--The use of defined daily doses helped identify cost and volume trends in specific areas of prescribing in fundholding and control practices. The basis on which funds are set needs improving, and defined daily doses may prove useful for setting volume targets within drug classes for all practices, whether fundholding or not.

General practice fundholding: observations on prescribing patterns and costs using the defined daily dose method.

BACKGROUND. At the time of the introduction of fundholding, a number of potential benefits and concerns about fundholding were debated. AIM. A study was undertaken to compare process and outcome of care in patients with different levels of physical, social and psychological need in 1990 and 1992 in six fundholding groups in Scotland. METHOD. Patients aged 16 years and over consulting with a range of marker conditions in 1990 and 1992 completed a pre-consultation health status questionnaire asking about physical, social and psychological problems, and a postconsultation satisfaction/enablement questionnaire asking about their ability to cope, and understand their illness. Main outcome measures were consultation length and satisfaction/enablement score. RESULTS. Of patients attending in the study period, 39% consulted for one or more marker condition. The proportion of patients reporting social problems rose between 1990 and 1992 for 11 out of 12 conditions. Overall, consultation lengths remained constant. Patients wanting to discuss social problems had significantly longer consultations than those reporting no social problems or problems they did not wish to discuss. The proportion of patients expressing enablement dropped for eight conditions and rose for four between 1990 and 1992. The decrease in the proportion expressing enablement remained after controlling for the rise in the percentage reporting social problems. Patients who had social problems they did not wish to discuss but a general health questionnaire score of five or more were the group reporting lowest enablement. Significantly more patients with pain, skin problems and digestive problems reported social problems and significantly fewer of them reported enablement in 1992 compared with 1990. Patients with diabetes, angina, chronic bronchitis and problems seeing fared relatively well over the study period. Some patients with psychosocial problems fared poorly (they had relatively short consultations and were unlikely to express an ability to cope/understand their illness). CONCLUSION. The issue of whether benefits to some patient groups from recent health service changes may be matched by disadvantage to other groups, for example those with clinical problems with no financial incentive to provide pro-active care or with psychosocial difficulties, is discussed.

Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome.

Objective: To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. Design: Questionnaire and record based study. Subjects: Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. Setting: Six practice groups in pilot fundholding scheme in Scotland. Main outcome measures: Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. Results: About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992, about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded “much better” to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. Conclusions: Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.

Evaluating care of patients reporting pain in fundholding practices

At the inception of the internal market in health care GP fundholding was seen rather as a ‘sidesho’ to the main reforms But as the reforms have worked through, GP fundholding has emerged as pivotal to the purchaserlprovider agenda and the changes now associated with GP fundholding will be major issues in directing future health care policy initiatives Drawing on empirical data from three Scottish regions, this paper argues that fundholding is now significant because GPs perceive benefits for primary health care The paper uses the data collected from the case studies in the regions to assess these gains on two levels: the ‘micro’ impact of fundholding on primary health care processes and the ‘macro’ issues raised for health care policy by involving GPs more closely in resource management Some GPs wish to use resource management as a vehicle for enhancing equity within the NHS, others are more concerned to manage resources so as to expand their practices into sites which combine primary, secondary and community health care, still others envisage developing the market to include monetary rewards for ‘efficient’ practices

The impact of fundholding on primary health care: accounts from scottish gps

Proposals for fundholding were greeted with scepticism by many general practitioners, and in Scotland the BMA persuaded the government to allow a scheme to test the arrangements as a demonstration project operating "shadow" practice funds. This allowed the six selected practices to set up administrative and computer systems without the worry of dealing with real money. The shadow fundholding scheme has since been extended to small practices and to a trial of fundholding for all services except accident and emergency. The six practices in the original pilot have all become fundholders and are beginning to effect improvements in the service to their patients. However, with more practices becoming fundholders negotiating contracts with providers is becoming increasingly complicated and more time and money needs to be put into this aspect.

https://www.bmj.com/content/bmj/306/6879/695.full.pdf

General practitioner fundholding: experience in Grampian.

After the agreement in January 1989 between the Minister of Health at the Scottish Office, Mr Michael Forsyth, and six groups of General Practitioners (GPs) in the Grampian and Tayside Regions of Scotland to embark on a 'shadow fund-holding' project, the Government agreed to promote an independent evaluation of the scheme. As a result, the Department of General Practice at Edinburgh University was invited to present plans to evaluate the working of and results of the scheme. Consultations with the Minister and Health Department officials, the general practices concerned, and staff of the two Health Boards involved took place during the first three months of 1990, and an outline protocol for the evaluation was approved and funded through the Chief Scientist Organisation for a three-year period from April 1990. It was agreed by all involved that piecemeal publications of results during the period of the research would be inappropriate, but with other attempts to evaluate fund-holding now being reported elsewhere in the UK, it has been agreed that an outline of issues being explored and the methods being used would be in the general interest. This paper first outlines the principal areas in which the evaluation is being focused, then describes the general methods being used, and finally comments on some of the problems encountered with the evaluation. The project should be seen as a descriptive beginning to what may well be a period of around a decade needed to appreciate the full implications of any major change in the organisation of health service provision.

The chief scientist reports ... The Scottish general practice shadow fund-holding project--outline of an evaluation.

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The chief scientist reports ... The Scottish general practice shadow fund-holding project--outline of an evaluation.