Primary care budget holding in the United Kingdom National Health Service: learning from a decade of health service reform

The United Kingdom National Health Service (NHS) has experienced 10 years of primary care budget holding in a variety of forms. Half of all general practitioners had joined the GP fundholding scheme by 1997, and many others had joined broader GP commissioning groups, but fundholders controlled only about 20% of the budget for hospital and community health services. Research on fundholding and commissioning groups suggests that delegation of budgets produced some gains in the range and effectiveness of services, but also had significant management costs and inequities. From 1999, all primary care professionals joined Primary Care Groups, which are now becoming Primary Care Trusts (PCTs). PCTs will control three-quarters of the healthcare budget and provide all primary and community services as well as commissioning hospital care. Control of a unified healthcare budget presents opportunities to improve quality, increase integration of services, reduce inequities and improve health, However, PCTs are threatened by a growing gap between capacity and expectations, and by continuing tension between devolution of power and increasingly prescriptive management by central government.