11 Purchasers, providers, and the future of clinical autonomy

Whereas GP-fundholding has been divisive, and even now is actively supported only by a minority, the purchaser-provider split has been generally popular with family doctors, and with good reason. In many areas, GPs find that for the first time since 1948, hospital specialists show some interest in consumer opinions about the service provided, and specialists providing a rotten service at last provoke real concern and eventual action from NHS administration. Adequately staffed and resourced for the first time, FHSA administrators who long wanted to do more than simply calculate pay for GPs, can now show some active interest in the work of primary care teams. Operating in some areas through locality commissioning which can include all GPs, not just fundholders, the purchaser-provider split has appeared to create favourable opportunities for co-operation between primary care teams and FHSAs, and a more equal dialogue with traditionally dominant hospital specialists.

These healthy developments have all followed the purchaser-provider split, and some, though not all, are probably caused entirely by the new economic dependence of hospitals on GP referral. However, looked at more carefully, the positive elements in this change need not necessarily depend on a purchaser-provider split, and might have been obtained better in other ways. Elected representatives of family doctors and other primary care workers could always have been included in all Hospital Management Committees, and been encouraged by the Department of Health to argue for their needs, based on evidence from clinical audit. FHSAs could always have been properly staffed by imaginative and well trained administrators, including people with Community Medicine skills, and providing networked information technology to catchment area practices. We didn’t have these things for two reasons: because governments believed stagnation in primary care was cheap, and believed all innovation must originate from hospitals; and because most GPs wanted to remain independent contractors, advancing at their own preferred speed, and generally failed to recognise any need for area planning. Both these obstacles steadily diminished throughout the 1970s and 1980s, and more positive policies would almost certainly have emerged, both from the Department of Health, and from the BMA and Royal Colleges, if they had not been derailed by Thatcherism. It is not difficult for vigorous policies of managed competition to appear more dynamic than no policy at all, but this does not mean that other policies could not have been applied, perhaps with much better effect.

Whether hospital specialists listen to community generalists, and whether community generalists listen to their patients and the people they serve, need not depend only, or perhaps at all, on mobilising the economic pressures of consumer demand. Andrew Wall reveals the real weaknesses of the purchaser-provider split at a more general level:

“The benefits of the purchaser-provider split, now seemingly the gospel of the public services of the western world, are by no means self-evident. Organisations need to have the capacity to learn if they are to be flexible and adapt to circumstances. At a very fundamental level of work, anyone at any level of the hierarchy will have ideas about how their job could be done differently and better. The purchaser-provider split introduces something inherently unnatural because there is a forced division between those who do the job and those who plan the job…. People and organisations are motivated by the prospect of being able to have a significant say in their futures. Rob them of that, and they become lacklustre, unimaginative, and in the end obstructive, if only to attempt to recover some sense of power

He is talking about something fundamental to any serious socialist philosophy, the essence of both Karl Marx and William Morris; the difference between creative work and paid drudgery.


The present purchaser-provider split applies not only to purchase through GP referral of routine specialist care at District General Hospital level, but also to purchase by DGH specialists of more highly specialised advice, interventions and support for which catchment populations of five million or more are necessary to maintain expertise and to allow reasonable economy. Given the complex and increasingly technical nature of hospital care, area commissioners would be stupid to ignore the opinions of those who actually do the work; but pushed to its logical conclusions, this is precisely what the essentially adversarial purchaser-provider split compels them to do.

A great advantage of the pre-“reform” centrally planned NHS was the balanced and rational distribution of secondary and tertiary specialist resources achieved throughout the UK by the 1970s, in marked contrast with the grossly irrational distribution of these services created by the competitive medical market in USA. As recent evidence on poorly organised cancer treatment has shown, the NHS still has a long way to go before general surgeons stop trying to do a bit of everything, and allow increasingly technical sub-specialists to maximise health gain for patients. Such failures are not the result of rational central planning, but of peripheral resistance to it, based essentially on the lack of medical accountability guaranteed by the 1948 compromise. As all belief in such unaccountability disintegrates, the scope for rational planning must increase.

By their increasing readiness throughout the 1980s to accept the disciplines of clinical audit (objective measurements of the processes and outcomes of care of defined populations) progressive doctors, both hospital specialists and community generalists, showed their acceptance of accountability in principle. Whether their less progressive colleagues would have followed them, without the coercion of the NHS “reforms”, will never be known, but though progress was already rapid before “reform”, the volume of audit has certainly increased much faster since. Whatever path we take in the future, this change is probably irreversible; though some may drag their feet, no doctors, specialists or generalists, are likely ever to claim a right to unaccountability in the future, or to deny that in the public interest, they must increasingly accept divisions of labour within a planned framework, providing they have opportunities to share in this planning themselves.

The foundation of accountability is truthfulness. This means that people must be allowed to measure their work themselves, or allow others to do so, without consequent reward or punishment. If the results of clinical audit are used for any purpose other than to resource deficiencies where these are found, they will become as detached from reality as the average self-administered income-tax return. The audit cycle has four component parts; agreement by the whole team on reasonable, measurable objectives; measurement of the extent to which these are actually being attained; revision of practice in the light of shortfalls revealed; and then remeasurement to assess consequent progress. This allows all workers to learn from their own measured experience, starting from any level of quality, without prior assumptions; properly resourced and with imaginative leadership, it can be enormously effective, in precisely the areas of greatest need. Because real (rather than legalistic) clinical accountability is a new category of thought, both professionals and the populations they serve must develop new customs to make full use of it. Local responsibility for assessment of area health needs, planning, and commissioning, shared by FHSAs, family doctors, local special interest groups such as the British Diabetic Association and Mencap, and elected representatives of the local community, could be a practical means of doing this.