Public Services Management: When the practitioner becomes the purchaser: Many doctors feel the only way to prevent a two-tier health service is for all GPs to become fundholders, reports Paul Gosling

LAST MONTH the British Medical Association decided to end its campaign against general practitioner fundholding. It is not that members now like the new system, but because they simply recognise reality. Even GPs who oppose fundholding are applying to become fundholders.

Many doctors say the only way to prevent a two-tier health care system becoming enshrined is for all GPs to become fundholders. Currently one in four of the population is registered with a fundholding practice, and by April next year that figure will be one in three.

There are considerable advantages to being a fundholder. Dr David Tod, a GP in London, is president of the National Association of Fund Holders. He sees great benefit to the patient as consumer. 'There are now outreach clinics, with consultants visiting surgeries. There is the introduction by fundholders of counselling and psychotherapy at practices. It is bringing services closer to the patient. These are strong benefits, particularly in non-urban areas. Another advantage is our use of the private sector, which reduces the pressure on the NHS.'

Dr Tod believes that the innovations introduced by fundholders are influencing the remit of the health service. One effect, he says, is to encourage consultants to prescribe generic drugs as a cost saving. Bernie Naughton, the honorary secretary of NAFH, adds: 'It is blurring the edge of primary and secondary care, which has been the bane of medical life.'

Some GPs, however, remain unconvinced and defiant. Dr John Kilpatrick, a GP in Leicestershire, refuses to become a fundholder. 'The main problem is that it creates a two-tier system. We were always promised that this would not occur, but we, the ground troops, believe it is occurring, and consultants and trusts say it is a two-tier system. I, as a supporter of the National Health system, think it is ethically wrong.

'If 100 per cent of GPs become fundholders it would not be a two-tier system, but I would then have to say, 'So why am I managing a fair proportion of the NHS for the Government?' In many cases fundholding is good for patients, but it is at the expense of other doctors' patients. It could break down the National Health Service, which I would not want to be responsible for.'

Dr Kilpatrick's practice was one of 60 which recently decided not to become fundholders, but instead to be involved with the district health authority in a more comprehensive partnership arrangement.

Dr Gillian Morgan, director of public health at Leicestershire Health Authority, explains: 'We've actively tried to involve GPs in our purchasing arrangements. We've had two GPs on each purchasing team. GPs are represented on our advisory committee.

'I've been a member of the local medical committee. We've had questionnaires and visits to GPs. It became clear that the average GP, who was not involved in the purchasing arrangements or on the local medical committee, wanted to be more involved in purchasing. So we have established another tier, not a consortium where just non-fundholders get together, but will involve all GPs, fundholders as well as non-fundholders.'

The advantage for GPs from arrangements like the one in Leicestershire is that they can be involved in making purchasing decisions, without being required to take on additional management and administrative responsibilities. Elsewhere, consortia of fundholders, called multifunds, are being established to relieve GPs from these unwelcome tasks.

Dr Richard Gibbs is chief executive of Kingston and Richmond district health authority, where a consortium has been established. 'The main advantage is to them. By pooling their management they have economies of scale, more efficient computing facilities, higher calibre managers, a better back office function. It is relevant to me if a multifund does strategic purchasing. The rules are that GPs are supposed to take their own purchasing decisions, not pass them up. The idea is to take decisions at the lowest level.'

The Kingston multifund will be established in April next year, and Dr Gibbs is nervously awaiting 15 September, when purchasing intentions must be published. The GPs will then be the real power brokers, as 80 per cent of local practitioners will, by next year, be fundholders, probably the largest proportion in the country. 'They will be the dominant purchaser. The main impact on services is from GP decisions. There is no point in my saying what is going on in clinical gynaecology, as it's not my decision any more.'

Another multifund, modelled on the Kingston approach, is being established in Birmingham, where Dr Fay Wilson, an innerc-tiy GP, has taken the lead in co-ordinating 100 practitioners. Purchasing decisions are discussed, but GPs remain responsible for their own budgets.

'It's a co-operative,' she says. 'It's not a giant consortium, but individual fundholders working together so that they can take a strategic view about purchasing, which is missing from fundholding.' While not becoming joint purchasers, says Dr Wilson, it does enable fundholders to make decisions which do not have the inadvertant effect of closing down hospitals which are still needed.

Inner cities, with a premium on land, tend to have smaller general practices, and have therefore proven less fertile for fundholding, but the approach taken by Kingston and Birmingham may be attractive.

Dr Wilson believes it is appropriate even for those GPs who are opposed to fundholding. She says: 'There has been widespread ideological opposition to fundholding, even among those who are doing it, but doctors are pragmatic people. It has been around for three years, and it is evident that a two-tier system is developing, and GPs have said that they are not prepared to have patients suffer for our principles.'

Dr Wilson says that their approach will safeguard local hospitals, by ensuring that purchasing decisions will be taken within a strategic context, while also giving practitioners the power to choose between locality and speed for operations, according to circumstance. It will also give GPs more influence over the district health authority, within an atmosphere of mutual help.

'This brings people together far more in a context. I'm not trying to get one up on a neighbouring GP. It's philosophy, and practicality, and some ideology - people working together in a more positive way.'

(Photograph omitted)