On the upside, fundholding has proved the biggest single agent for change in the NHS since 1991. Fundholding GPs have been able to get their patients quicker access to hospital. They have proved good at cutting waiting times for out-patient appointments. Many have been able to insist - with the threat that they will take their business elsewhere - that hospitals respond better to their patients, answer letters promptly and change the way they provide services. Family doctors have ceased to be merely supplicants on their patients' behalf to all-powerful hospital consultants who previously had no incentive other than their own goodwill to respond to GPs' and patients' concerns about the way services were organised and provided. More flexible and responsive services have resulted.
The downside is equally well-known. With only 40 per cent of the population covered, a two-tier system has developed. Patients of non-fundholders have waited longer. In some cases, clinical priorities have been distorted as fundholding patients have been treated ahead of others with more pressing conditions by hospitals desperate not to lose fundholders' business. Non- fundholding GPs have not had the same flexibility to improve their services by making savings on one part of their budget to be spent on another. And there have been concerns about how some fundholders have spent the savings they have made - too often on better premises that mean better pensions for doctors rather than simply pleasanter surroundings for patients.
So what is to be done? The answer is not to throw the baby out with the bathwater. Since it started, fundholding has been evolving. Tighter rules now exist over how savings can be spent, and tighter rules yet may be needed. The division of budgets between fundholders and non-fundholders is becoming fairer. Non-fundholding GPs have persuaded health authorities to achieve similar improvements in waiting times and flexibility for their patients as those pioneered by fundholders. The way to end the two-tier system, therefore, is not to abolish fundholding but to find ways of bringing its key benefits to all.
The Government, to be fair, has begun to do this. Around the country, a plethora of pilot projects is examining a variety of different ways to let GPs (fundholders and non-fundholders) buy and commission services. Many of these, by grouping GPs together, tackle the two-tier problem. And several ensure that fundholders operate within an overall framework provided by local health authorities which reduces the risk that the more enthusiastic will benefit their patients at the expense of others. Some projects, at least, may reduce the administrative burden that, the Which? survey suggests, is leaving some GPs busier managing their budgets than running their practices in the way patients want.
Both fundholding and non-fundholding are evolving, therefore, and the sharp distinction between the two is beginning to erode. Labour might do better to examine ways of taking that further, perhaps allowing fundholding to develop into something rather different, instead of simply chanting its five-year-old mantra that when it gets to power it will "abolish" fundholding, gains and warts and all.