Will budget holding go off with a bang or a whimper?

Chris Ham
GP budget holding will play a major part in the coalition government’s plans for the NHS. So what lessons should be learnt from previous NHS attempts to involve GPs in commissioning? And what should be drawn from other countries' experiences as the government develops its plans?

Evidence from GP fund holding, total purchasing and practice-based commissioning shows that GPs who control budgets can contribute to improving the performance of the NHS. Benefits include reducing the costs of prescribing, providing more services out of hospital, and improving access to care.

These benefits have been particularly apparent when entrepreneurial GPs have worked closely with experienced managers. One of the lessons from the past is the importance of a sufficient number of GP leaders taking an interest in budget holding, and having the resources to hire staff with the right expertise.

We also need to ensure that the size and scope of budget holding are appropriate. While larger groups of GPs are better able to manage risks, they are often less equiped to introduce change quickly. A menu of options should be offered as it is unlikely that one size fits all.

GP commissioners in the past have struggled to bring about major changes in the configuration of local services where these have been needed. It will be important then to maintain a role for primary care trusts (PCTs) in leading on these changes and taking responsibility for aspects of commissioning that GPs lack the competence or motivation to undertake.

Experience in the United States underlines the role for a body like a PCT to assess the performance of GPs as budget holders. This includes reviewing the quality of care delivered by budget holders and ensuring that conflicts of interest do not arise, for example, if budget holders decide to use their resources to provide more care themselves.

One of the most difficult questions is what balance should be struck between risk and reward? If the government is committed to offering hard budgets, will GPs be at risk for any losses incurred and will they be able to benefit from surpluses generated? Equally important, will they be able to use some of the surplus to increase their personal income and not just improve services for patients?

The fear of knavish behaviour on the part of some GPs may blunt the appetite of policymakers to allow GPs to enhance personal income. If this is the case, then the willingness of entrepreneurial GPs to take an interest in budget holding may diminish. Finding a way through this dilemma will determine whether budget holding goes off with a bang or a whimper

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