Sir: Your assertion that "GP Fundholding has plainly worked" cannot be allowed to pass unchallenged ("The Positive Side of Fundholding", l June). My review of the literature on fundholding suggests that there is only limited evidence in support of your position.
Thanks to the Government's refusal to fund proper evaluation studies, fundholding remains woefully under-researched. Only two series of studies have attempted systematic comparison of fundholding practices with non- fundholding controls, and neither of them has found unambiguously in favour of fundholding.
Your argument depends heavily on fundholder's claims of service improvements, but these are not reliable evidence, since many of them can be matched by non-fundholders. Of the innovations attributed to fundholding, some are of unproven clinical value (eg, direct access physiotherapy) while others (eg, consultant outreach clinics) are questionable on cost-effectiveness grounds. One consultant has estimated that for eight patients seen in an outreach clinic, 70 could be seen in hospital.
What is certain is that fundholding is expensive to run. In 1989, the Government estimated that fundholding administration would cost pounds 15.6m per annum. In 1993-4, it cost pounds 66.6 million. At 3.5 per cent, fundholding is more than twice as costly to administer as health authorities or non- fundholding commissioning groups. Since administration is largely a fixed cost, this expense is certain to rise if and when fundholding is extended to smaller practices.
Until more reliable evidence becomes available, perhaps your claims for fundholding should be moderated.
Lecturer in General Practice
The Medical School
Queen's Medical Centre
University of Nottingham
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