Promoting clinical effective practice. Attitudes of fundholding general practitioners to the role of commissioning

Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995-1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence-based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically-driven policy or they will resist it.     

Efficiency of care at the primary-secondary interface: variations with GP fundholding

The aim of the study was to investigate the processes of referral for out-patients care and the interface with general practice, from the perspective of the patient, the patient's general practitioner and hospital specialist. The analyses reported here present variations with fundholding and non-fundholding general practice. The design was a questionnaire survey of out-patients, their hospital specialists and general practitioners, in six, randomly sampled district health authorities in the North Thames Region, with stratification by area. The measures included validated items and scales on process, quality and patient satisfaction with services. Fundholders were more likely to have technical equipment and services available within the practice. There were no differences between fundholders and non-fundholders and the number of out-patient attendances made by their patients, hospital out-patient waiting list times, patients' waiting times in hospital clinics, nor in patients' satisfaction with out-patients and other process indicators. Fundholding is currently being replaced with the proposed wider locality commissioning schemes, with GPs, health authorities and other purchasing bodies acting in partnership. Health authority commissioning will be required to reflect the preferences of GPs. Participants in these schemes will need to pay particular attention to the areas where research indicates that fundholding GPs made little difference to increasing the efficiency and effectiveness of health care both in their own practices and at the primary-secondary care interface.     

Prioritizing services: GPs' views, fundholders versus non-fundholders

Aims to assess the level of agreement between priorities of service provision in 20 discrete clinical areas, as laid out in a district health authority (DHA) purchasing plan, and the views of GPs in the catchment area of that authority and to test for a statistically significant difference between the views of fundholding and non-fundholding GPs. A 74 per cent response rate was achieved, and analysis suggested that local GPs' views were broadly in line with their DHA strategy, and that a significant difference existed between the views of fundholders and non-fundholders in only one treatment area, namely that of lithotripsy. Concludes that the postal questionnaire is a cheap and easy method of assessing the views of GPs on prioritizing issues. As yet there is little difference between fundholding and non-fundholding GPs in this area of decision making.     

The effect of fundholding on prescribing and referral costs: a review of the evidence

In 1990 the UK Government announced the introduction of general practitioner (GP) fundholding whereby GPs were given a budget from which to purchase some health care services. The UK Government is at present piloting total fundholding which extends the partial model by allowing GPs in some practices to purchase all their health care services. If other countries intend to adopt schemes similar to the fundholding model then it is important that the success or otherwise of the UK experience informs their health care policy. The objective of this paper, therefore, is to review all the available quantitative evaluative evidence of the effect of (partial) fundholding on general practice. A total of 17 published quantitative studies evaluating fundholding were found, however, 8 of these were papers relating to 2 studies, therefore only 13 studies were reviewed. These studies examined the impact of fundholding only with regard to prescribing and referral behaviour. The results of these studies indicate that fundholders appeared to: (i) constrain their prescribing and referral costs; (ii) increase their generic prescribing rate; and (iii) not inflate their costs prior to joining the scheme. This review showed that there is a dearth of high quality research evidence evaluating fundholding referral behaviour whereas data on differences in prescribing costs is relatively abundant. The studies reviewed did not evaluate the effect of fundholding on patient health status, quality, patient choice or equity criteria. The difficulties involved in evaluating fundholding model presents a considerable challenge to the evaluation of total fundholding.     

The impact of budgets for gatekeeping physicians on patient satisfaction: evidence from fundholding

Between 1991 and 1998 English general practices had the option of holding budgets for prescribing and elective secondary care. Fundholding was reintroduced in 2005. We examine the effect of fundholding on patients' satisfaction with their practice, using a cross section of 4441 patients from 60 practices in the last year of fundholding (1998). We employ instrumental variables to allow for the endogeneity of fundholding. Patients of fundholders were less satisfied with the opening hours of their practice, their GP's knowledge of their medical history, with their GP's ability to arrange tests and willingness to refer to a specialist, and were more likely to agree that their doctor was more concerned about keeping costs down. Fundholder practices performed better on a number of process measures of care, and fundholding patients were more satisfied with additional non-medical services provided by the practice. The probability that patients were overall at least very satisfied with their GP practice was 0.073 (95% CI, 0.009-0.138) smaller in fundholding practices.     

General practice fundholders' prescribing savings in one region of the United Kingdom, 1991-1994

Since 1991, fundholding general practitioners in the UK have had a financial incentive to contain prescribing costs. Research has confirmed that fundholding practices have contained their prescribing costs more effectively than non-fundholding practices, but how much fundholders have actually saved by changing their prescribing is difficult to quantify. Fundholders are allocated a prescribing budget, and the underspend on this budget has been taken to represent savings produced by changing prescribing behaviour. However, this assumes accuracy of budget setting, which has been questioned. The objective of this study was to estimate the true savings in prescribing made by fundholders during the first 3 years of fundholding, without making assumptions about the accuracy of budget setting. We compare this to underspends on prescribing budgets. The results suggest that budget setting did not give fundholders over-generous budgets and that budget underspends are justified by the true savings in prescribing.     

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.     

Health care management: models for evidence-based practice.

Presents models suggesting how research evidence can best be operationalised within health care commissioning. Models were derived from data gathered from surveys of Scottish health board managers and GP fundholders regarding the use of information in commissioning from 1995 to 1997. Feedback on the models was obtained subsequently from practitioners in 1998. Two models, one for health board managers and the other for GPs, are presented. These include critical success factors in achieving evidence-based commissioning and factors that are likely to predispose and precipitate evidence-based practice. Given a culture demanding transparency, accountability and continuing improvement, the models provide tools for reflection, evaluation and planning. In addition, they identify a pragmatic role for managers in evidence-based commissioning and provide a framework for audit.     

The effect of financial incentives on gatekeeping doctors: evidence from a natural experiment

In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders' admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders' chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID).     

Emergency admissions. Ours to reason why

Is GP fundholding a factor in the steep rise in emergency admissions? Guy Boersma's research suggests that managers should investigate why fundholders have been able to contain the pressure for growth in emergency admissions far more successfully than non-fundholders.     

The effect of practice budgets on patient waiting times: allowing for selection bias

Under the UK fundholding scheme, general practices could elect to hold a budget to meet the costs of some types of elective surgery (chargeable admissions) for their patients. It was alleged that patients of fundholding practices had shorter waits for elective surgery than the patients of non-fundholders. Comparison of waiting times between fundholding and non-fundholding practices are potentially confounded by selection bias as fundholding was voluntary. We estimate the effect of a practice's fundholding status on the waiting times of its patients using both cross-sectional methods (OLS, propensity score, instrumental variables, Heckman selection correction and Heckman heterogenous effects estimators) and difference in differences methodologies to correct for selection bias. The estimated effect of fundholding status was to significantly reduce the waiting times for chargeable admissions of the patients of fundholders by 4.1-6.6% (or 4-7 days) with the instrumental variables and Heckman selection correction estimators yielding the highest estimates. We also find that patients of fundholding practices had shorter waits (by 3.7% or 2 days) for non-chargeable elective admissions, suggesting that fundholders were able to obtain shorter waits for all types of elective admissions.     

Changing role of the family physician in British National Health Service

Over the last ten years the traditional role of primary care in Great Britain has been undergoing major changes with the major impact being the introduction of what is termed "GP fundholding", a process by which GPs hold budgets to purchase care from hospitals on behalf of their patients. This paper addresses how the system of fundholding operates in practice and points out the difference between the new and the previous system in which the health authority would plan care for the whole of a district and costs by hospitals would be covered by an all-inclusive system. The paper studies the rationale of the introduction of the fundholding and examines the evidence on how successful the approach has been. With reference to a systematic literature review of the evidence on fundholding's outcomes undertaken by the author, the paper examines the evidence for and against fundholding under the following headings: efficiency, equity, quality, choice and responsiveness. The paper then addresses more recent changes to the British health care system and shows how these have changed the role of the family doctor irrevocablly.     

Financial incentives,competition and a two tier service: lessons from the UK National Health Service internal market

The experience of General medical practitioner (GP) fundholding is analysed for evidence of the response by family doctors to financial incentives. An analysis of consultant outreach, the local provision of out-patient services, in Scotland finds little evidence of a response, based on comparing the experience of fundholders with non-fundholders. At least in the case of hospital based services, financial incentives seem to be of secondary importance. Financial incentives for such services depend on consultant compliance which, arguably, was missing when it came to creating a two-tier service which deliberately favoured patients from fundholding practices.     

Access to the evidence base from general practice: a survey of general practice staff in Northern and Yorkshire Region

AIM: To identify and describe current methods of making health related research evidence accessible to general practice staff in the Northern and Yorkshire Region. METHOD: A postal survey questionnaire of general practice staff in the Northern and Yorkshire Region. RESULTS: At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of differential access to information resources between different professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available. CONCLUSIONS: At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why different professions working in the same practice setting have differential access to information resources available in primary care.     

Management of bibliographic information by Dutch researchers in general practice

BACKGROUND: As a result of changes in information technology and the rapid growth of publications methods of searching the literature have changed. Systematic searching of the growing literature has become very important. It is not known whether researchers in general practice search systematically, and whether they have incorporated computerized sources in their research practice. OBJECTIVES AND METHODS: We aimed to assess the methods of literature research used by GPs. We interviewed eight GP researchers, two information specialists and a psychologist working in primary health care organizations. RESULTS: The GP researchers began their search in their private book collections, or asked colleagues for information. Later in the search process, they used computerized information sources. Medline on CD-ROM and the computer-based indexes of two Dutch journals were most widely used. The GPs found it difficult to locate the appropriate terms to describe their research questions. Knowledge of the methodology of literature research, and skills required to use the information sources efficiently were lacking. There was a need for instruction and training in the use of information sources. GPs need a telephone help desk where their questions can be answered adequately. CONCLUSIONS: GP researchers search the literature unsystematically. Although computerized databases were being used, knowledge and skills related to the use of these information sources must be improved.      

Primary care groups. Staff's counsel

Staff are concerned that the establishment of primary care groups may lead to more direct employment of community staff by GPs. PCTs will have to control staff resources if they are to plan services of maximum benefit to patients. As primary care trusts develop, practice staff should be given the option of transferring their employment to the trusts. Regional clearing house arrangements should be established to assist the redeployment of NHS and fundholding staff displaced by the establishment of PCGs.     

Electronic primary care guidelines with links to Cochrane reviews--EBM Guidelines

In Finland, guidelines have been used in primary care since the late 1980s to bridge the gap between research evidence and practice. From the very beginning, the electronic format has been the primary source for EBM Guidelines (EBMG). Although also published on CD and in print, the guidelines are currently mostly used via the Internet. Keeping more than 1000 guidelines up to date is a great challenge to the editorial group, and several methods are used to guarantee the quality. The Cochrane Library has become the most important source of information for the guideline producers and all Cochrane reviews relevant to GPs are summarized and linked to the guidelines. In this article we present our experience of producing the electronic guidelines for GPs, the methodology used, and data on the clinical use of these guidelines and their Cochrane links. We also discuss the barriers and facilitators to our process and present ideas for future development.     

Partnerships in purchasing: development of consortium-based purchasing among GP fundholders.

In the last few years there have been considerable changes in the National Health Service (NHS) in the UK. Arguably the most significant of these has been the introduction of competition. Central to this development has been the introduction of general practice (GP) fundholding, whereby practices purchase health care for their patients directly from competing suppliers. Those practices which have become fundholders have faced considerable challenges in developing their purchasing function, given the complexities of contracting within the context of the NHS internal market. Although one of the original aims of GP fundholding was to facilitate locally responsive purchasing, such have been the complexities of contracting that many fundholding practices have attempted to reduce the managerial demands of purchasing through membership of purchasing consortia. Based on an in-depth study of GP fundholders across Scotland, this paper explores the development of consortium-based purchasing. Specifically, this paper seeks to address three issues central to the evolution of such consortium-based purchasing. Firstly, the patterns of organizational structure and the operational dynamics of such consortia. Secondly, the impact of such consortia on the process of fundholder purchasing. Thirdly, the managerial implications of purchasing through such consortia for the participating practices. In addressing these issues, it will examine whether such patterns of purchaser development have impacted on the evolution of locally responsive purchasing.     

Treatment and referral decisions under different physician payment mechanisms

This paper analyzes and compares the incentive properties of some common payment mechanisms for GPs, namely fee for service (FFS), capitation and fundholding. It focuses on gatekeeping GPs and it specifically recognizes GPs heterogeneity in both ability and altruism. It also allows inappropriate care by GPs to lead to more serious illnesses. The results are as follows. Capitation is the payment mechanism that induces the most referrals to expensive specialty care. Fundholding may induce almost as much referrals as capitation when the expected costs of GPs care are high relative to those of specialty care. Although driven by financial incentives of different nature, the strategic behaviors associated with fundholding and FFS are very much alike. Finally, whether a regulator should use one or another payment mechanism for GPs will depend on (i) his priorities (either cost-containment or quality enhancement) which, in turn, depend on the expected cost difference between GPs care and specialty care, and (ii) the distribution of profiles (diagnostic ability and altruism levels) among GPs.