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The New NHS: Fit for the future?
The new system is built on cooperation
The NHS is undergoing a radical restructuring - but critics fear that without new investment the same problems will continue to blight the service.

The main theme of the changes is to replace the competition engendered by the internal market with a new ethos of co-operation.

Ministers, like their predecessors in the Conservative administration, are keen that GPs should drive reform in the NHS, and decide where resources should go.

However, they have scrapped the controversial GP fundholding scheme under which individual GP practices were given direct control of large sections of their health care budget.

Critics claimed the scheme was divisive because it created a "two-tier service" with fundholders' patients often being offered hospital treatment more quickly than patients from non-fundholding practices.

It was claimed that fundholders received more than their fair share of NHS funds, particularly when the scheme was first launched in 1991. Fundholders, however, argued they had more incentive to manage their funds carefully than health authorities, who managed funds for non-fundholding GPs en masse.

The new system

The government is to replace fundholding with a system of primary care groups (PCGs) designed to ensure that all patients are treated the same.

GPs - together with other health and social services professionals - will join forces in PCGs covering approximately 100,000 patients to decide together how to purchase hospital services.

PCGs will have to work to a three-year Health Improvement Programme drawn up the local health authority to ensure a consistent approach across a locality.

A National Institute for Clinical Effectiveness will promote high quality guidelines for treatment based on scientific research, and a Commission for Health Improvement will intervene where local standards were failing.

The government has also stressed that hospitals, which under the Tories were encouraged to compete for business, must now co-operate to ensure that patients get the best care possible.

'Welcome change'

Many GPs have welcomed the introduction of PCGs as way to reduce inequality in the NHS.

But they also fear that the new system could be a way for politicians to shirk their responsibility for underfunding in the NHS.

With finite resources available, and demand seemingly infinite, GPs warn that it is inevitable that some treatments will have to be rationed, particularly as the new system will inherit the debts run up in previous years.

They fear that rather than blame the politicians for failing to put sufficient funds into the health service, patients will blame their doctor if they are told that treatment is being denied.

A survey by Doctor magazine found that 82% GPs thought they would be held more personally accountable for rationing decisions under the new system.

With intense pressures on budgets, GPs are also worried their clinical freedom to prescribe and refer in the best interests of their patients will be curtailed in the quest to save money.

Effect will be limited

Dr Simon Fradd
Dr Simon Fradd says more resources are needed
Dr Simon Fradd, deputy chairman of the British Medical Association's GP committee, said: "The introduction of PCGs is unlikely to have any great effect at all.

"Having pared back NHS resources to the bone there is not now sufficient total capacity in terms of hospital beds to deal with even a predictable increase in demand, such as an outbreak of flu."

Dr Fradd hoped that the involvement of public representatives in PCG meetings might, however, increase pressure on the government to make more resources available for the NHS.

He said: "Doctors have been wary about the involvement of lay people in PCGs, but I think it might be tremendously empowering. They might echo what health service practitioners have been saying all along - that if you want a quality service it is no good using scientific developments as an excuse to cut the number of hospital beds.

"If we kept some of the those beds waiting lists might get shorter and when there is a peak in demand then there is some spare capacity."

See also:

27 May 98 | Health
19 Oct 98 | Health
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