Total purchasing
in primary care
365
Journal of Management in Medicine,
Vol. 13 No. 6, 1999, pp. 365-372.
# MCB University Press, 0268-9235
Received July 1999
Revised August 1999
Accepted September
1999
Total purchasing in primary
care: three case studies
Stephen Abbott
Senior Research Fellow, Health and Community Care Research Unit,
University of Liverpool, Liverpool, UK
Stephen Harrison
Professor of Health Policy and Politics, Nuffield Institute for Health,
University of Leeds, Leeds, UK, and
Nicola Walsh
Fellow, Health Services Management Centre, University of Birmingham,
Birmingham, UK
Keywords Purchasing, Health care, General practice, United Kingdom
Abstract Total purchasing in primary care (TPPC) was piloted in the mid-1990s, first by four
``pioneer sites'', and later by over 80 first and second waves of ``pilot sites''. Separate evaluations
of three of the pioneers show that they faced challenges similar to those experienced by the pilot
sites, namely: the need to develop organisations which were effective both internally and, in their
relationships with other health-care agencies, externally; and the difficulties encountered when
attempting to change the behaviour of local acute care providers. Although GP fund holding and/
or TPPC have had some successes in influencing the pattern of delivery for some elective and
community services, the challenge of reducing hospital admissions and lengths of stay remains
formidable.
Introduction
Although the allocation of resources in the UK National Health Service (NHS) has
for some time been shifting gradually in favour of primary care (Bloor and
Maynard, 1993), it is only since 1991 that formal organisational arrangements have
begun to embody the idea of a ``primary care-led NHS'' (DH, 1994). From that date,
various forms of voluntary budget (or fund) holding for secondary care services on
the part of primary care physicians (General Practitioners: GPs) developed rapidly.
By 1996 about half of the population was registered with such a GP Fundholder
(GPFH) (Audit Commission, 1996). Some GPFHs held funds to pay only for elective
services for their registered patients, while others (variously referred to as ``total
fundholders'', ``total purchasers'' or ``total purchasers in primary care'' ± hereafter
TPPCs) were allocated budgets to pay for all secondary, including acute, care.
TPPC has been defined for working purposes as:
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Fieldwork at Pioneer A was undertaken by Nicola Walsh and Jonathan Shapiro, with assistance
from Mike Davidge in the analysis of activity data: the study was funded by the NHS Executive
Anglia and Oxford. The majority of fieldwork for the study of Pioneer B was undertaken by
Stephen Abbott, with assistance from Jenny Jefferson; the study was funded by the NHS
Executive North West. The majority of fieldwork for the study of Pioneer C was undertaken by
Jenny Jefferson, with assistance from Steve Harrison and Maxine Craven; the study was funded
by Bradford Health. The authors wish to thank all respondents.