08 October 2004
GP practice-based commissioning must avoid the inequalities associated with earlier experiments in primary care purchasing, the British Medical Association warned this week.
Ministers announced on October 6 that all GP practices in England would have the right to hold an indicative budget to buy care for their patients from next April.
The money will be devolved to practices from primary care trusts' budgets, and ministers hope family doctors will use their purchasing power to move many of the 45 million hospital outpatients' appointments a year into less expensive GP surgeries or community hospitals.
Practices will be allowed to keep 50% of any savings they make to reinvest in services for patients, although they will be expected to balance the books over three-year cycles. Their budgets could be withdrawn if they failed to do so.
PCTs will continue to negotiate contracts on behalf of practices that do not wish to be involved in the scheme and will carry out the administrative tasks needed to support practice-based commissioning. They will also negotiate contracts for low-volume, high-cost care to prevent practices' budgets being decimated by complex cases.
Many commentators have claimed that the initiative is a resurrection of the maligned GP fundholding system, which was abolished by Labour in 1998. Fundholding gave participating GPs additional cash that enabled them to bypass waiting lists.
The BMA's GP leader Hamish Meldrum insisted past mistakes cannot be repeated. Like fundholding, practice-based commissioning will be voluntary, potentially leading to budget-holding 'haves' and non budget-holding 'have-nots', he said.
'If it is to be successful, this scheme must ensure both equity of access and quality of service for all patients, and fair rewards for the practices that will take responsibility for managing these complex processes,' he said.
However, health minister John Hutton dismissed claims that he was reviving fundholding. Unlike the latter, practice-based commissioning will apply to all services, not just planned surgery, he said.
Participating practices would not receive extra cash and, with standard tariffs being introduced under payment by results, contracts would be negotiated on the basis of quality, not cost.
'PCT and GP practices should see practice-led commissioning as an opportunity to change the NHS from the bottom up,' he added.
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