From general practice to primary care: The industrialisation of family medicine in Britain

Journal of Public Health Policy,  2002  by Iliffe, Steve

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INTRODUCTION

THE emergence during the late 1990s of governments of the "Third Way" (Clinton, Blair, Schroeder, the Olive Coalition) has had implications for health services development and reform, and in particular for the trend towards privatisation of health care. This paper is an attempt to understand underlying trends in health service policies and development using a model of industrialisation as a theoretical framework, taking British general practice as a case study.

In this discussion paper I will make three assumptions:

1. Neo-liberalism as an economic and social policy is in retreat, and is being replaced with market regulation by centre-left governments, which have to work with or through a legacy of institutions, practices and ideas inherited from neo-liberal predecessors.

2. Cost-containment in health services will not leave the policy agenda, and is not simply an expression of a neo-liberal perspective on health care. In other words, all health services, however organised, will face the same problem of resources being insufficient to meet demand for health care.

3. A health service is a multi-unit enterprise providing a multi-component service, and organisationally is equivalent to a very large, diversified company. Although public health services are not for-profit enterprises, they may share characteristics of such enterprises, particularly where these characteristics offer methods of cost-containment.

Industrial development follows its own logic, and governments may have only a limited impact in shaping that logic. The current respite from neo-liberal policies in health care in some parts of Europe does not, therefore, imply an end to the underlying tendency towards solving problems in health care using market mechanisms. Given this argument, I want to try and answer the question: to what extent has general practice in Britain's NHS adopted industrial modes of organisation from productive (for-profit) industries?

DEVELOPMENTS IN BRITISH GENERAL PRACTICE

FRANCHISE DEVELOPMENT Developments in British general practice within the National Health Service can be described as occurring in three phases: a long phase of evolution from 1948 to 1990; a short period of attempted market reform, from 1991 to 1999; and a reversion to control and planning after 1999. The long term trends in the organisation of British general practice between 1948 and 1990 are shown in Table 1, and are described in detail elsewhere (1,2). During this period British general practice functioned as a franchise, with all the advantages and disadvantages of this form of industrial organisation. Franchises can grow quickly, utilising the local knowledge and energy of entrepreneurs whose risks are reduced by the franchiser, but once their range of services expands they have problems maintaining the quality and consistency of their activity.

MARKET REFORMS Engagement of British general practitioners in market reforms through fundholding (1991-9) produced much political conflict but little benefit to health care. Fundholders were expected to promote competition between hospitals for their custom, and this market was expected to function as a retail market (a type 2, market in health service management terms) (3). The successes of some fundholders in creating a competitive environment led some analysts to overstate the impact of the move towards a market-based NHS (4), and the evidence suggests that the overall impact of the marketisation policy of this period on the organisation and performance of general practitioners and hospitals was modest (5,6). Fund-holding appeared to promote greater inequality between practices and reduced the capacity of the NHS to plan strategically (7). It achieved some cost savings in prescribing, but not in referrals to specialist care, and incurred substantial additional administration and transaction costs without demonstrating any improvement in health outcomes, nor any widening of consumer choice (8).

PRIMARY CARE GROUPS In the current phase of reforms general practice is being incorporated into health service management through the formation of primary care groups and trusts, which in effect are collectivising previously semi-autonomous practitioners. The primary care groups require general practitioners and primary care teams to improve the health of their communities by addressing the health needs of their population, promoting the health of that population and working with other organizations to deliver effective and appropriate care (9). Potential problems include the likely negative impact of compulsory enrolment of potentially reluctant general practitioners (10), the wide variations in prescribing and referral that will impede the introduction of capitation-based funding (11), the tendency of the NHS to undervalue the motivation of practitioners and overvalue sanctions (12), and the risk that the whole process of change will degenerate into a bureaucratic 'name and shame' culture (13). This swing back towards a social rather than market model still contains features from the earlier market orientation, which are discussed elsewhere (14). The economic structure being created appears to be more of an industrial market (type 1 market) than a retail one, with supportive rather than competitive relationships between health care providers.