Fundholding in the south Thames Region. Fundholders' prescribing costs: the first five years. GP fundholding and prescribing in UK general practice: evidence from two rural, English Family Health Services Authorities. Alterations in prescribing by general practitioner fundholders: an observational study. Effects of a monetary incentive on primary care prescribing in Ireland: changes in prescribing patterns in one health board 1990-1995. Unintended effects of a cost-containment policy: results of a natural experiment in Germany. GP fundholding and the costs of prescribing: further results. The extent of the two tier service for fundholders. Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs.
The general practice fundholding scheme is now at the forefront of the National Health Service (NHS) reforms and should lead to the more efficient use of services by making general practitioners more aware of the financial consequences of their clinical decisions. However, there is a concern that adverse effects may also occur.
                To monitor the changes occurring in a sample of fundholding and non-fundholding practices between 1992 and 1995, including providing care nearer to patients, the mixed economy of care, the efficiency and costs of fundholding, and the commitment of fundholders.
                Fifteen first-wave practices, four second-wave practices, and four non-fundholding practices in the former South East Thames Region took part in the study. Information was collected using interviews, questionnaires, prescribing data, and annual fundholders' income and expenditure accounts.
                Consultant clinics were set up in 10 different practices in 15 different specialties, and paramedical clinics in 12 different practices. Physiotherapy and mental health clinics constituted over 90% of the paramedical hours. Fundholders had private arrangements with an individual consultant or practitioner for approximately half of the contracted hours in both types of clinics. Fundholders had lower overall prescribing costs than non-fundholders, but the overall costs for prescribing for all groups had risen by about one third over three years.
                While outreach clinics may help to provide for the needs of patients with common conditions, they may lead to the fragmentation of services. The provision of primary care by those who are not NHS employees needs careful consideration. Recent policies for general practice have emphasized its role in disease prevention and in coordination of care for chronic illness. Fundholding also promotes two additional roles, the purchasing of care and the development of in-house facilities. Combining these different functions presents a considerable challenge. To determine whether the first five waves of English fundholding practices have reduced their prescribing costs relative to non-fundholding practices, and the duration of any reduction achieved.
                Analysis of item and cost data for all general practices in England in the six years from April 1990 to March 1996. The practices of each of the first five waves were identified at the Prescription Pricing Authority.
                All general practices in England.
                Changes and rates of change in net ingredient cost per prescribing unit, and changes in number of items per prescribing unit in fundholding practices, before and after fundholding, relative to continuing non-fundholders.
                Absolute prescribing costs increased over the six years, by 66% in the continuing non-fundholders and by 56-59% for fundholders. Successive waves of fundholders showed a similar pattern of change: a small relative reduction in the pre-fundholding year, maximum relative reduction in the first year, and a declining relative reduction in the second and third years. After this, their increases in costs were largely similar to those of non-fundholders. The number of items dispensed remained stable over the six years in all groups.
                The real budgets operated by fundholders were associated with a reduction in costs of about 6% relative to continuing non-fundholders, and this saving seemed to be retained during the study. The relative reduction was small compared with the absolute increase seen in all groups and disappeared after the third year of fundholding. It was brought about by lowering the average cost per item rather than by giving fewer items. Two separate prescribing budget regimes (part of GP fundholding and the indicative prescribing scheme) were introduced into UK general practice in April 1991 in an attempt to contain the growth in NHS expenditure on prescribed drugs.
                The aims of this study are (i) to examine whether the fundholding scheme has been more effective at containing prescribing cost growth than the indicative prescribing scheme and (ii) to ascertain whether its implementation, at a practice level, has been affected by local circumstances and conditions.
                Prescribing cost data were collected from two rural, English Family Health Services Authorities for the financial years 1990/1991 to 1993/1994. Exploratory analysis was performed using regression analysis and nonparametric statistical techniques.
                Initially, the fundholding scheme has been the more effective at containing expenditure on prescribed drugs. However, the implementation of the schemes in rural areas has probably been affected by the existence of practices with permission to dispense drugs to their own patients, due to a lack of pharmacies in such areas. To compare prescribing in general practices before and after they become fundholders to assess whether this affected prescribing patterns.
                Analysis of prescribing data (PACT) for one year before and one year after practices become first, second, or third wave fundholders and comparison with practices that were not fundholders during any part of the study.
                Prescribing costs (net ingredient cost per prescribing unit), prescribing volume (items per 1000 prescribing units), net ingredient cost per item, and percentage of generic prescribing.
                Former Mersey Regional Health Authority.
                100 fundholders (20 first wave, 31 second wave, 49 third wave) and 312 nonfundholders.
                Prescribing costs and volume rose throughout the study in all groups. In all three fundholding waves the rate of increase of prescribing costs was significantly lower than for nonfundholders. Both cost per item and prescribing volume tended to decrease, the former probably because of a significant increase in generic prescribing. Fundholding and non-fundholding practices differed in several respects.
                Fundholding has altered practice prescribing patterns compared with those of nonfundholders, increasing generic prescribing and reducing the rate of increase of prescribing costs. In an attempt to curb the rapidly rising costs of primary care prescribing in Ireland, the government introduced a financial incentive scheme in 1993, to encourage general practitioners to restrain their prescribing.
                To investigate the effects of a financial incentive scheme on GP prescribing in Ireland on prescribing costs and volume, and on some specific therapeutic areas.
                Prescribing for 3 years before (1990-1992) and 3 years (1993-1995) after the introduction of incentives, based on a defined cohort of 233 general practitioners in the area of one health board. GPs were divided into tertiles based on their performance against their prescribing budgets into 'savers' (generally underspent and received incentive payments), modest overspenders and large overspenders.
                Savers were always lower cost prescribers than the other groups. They contained their rate and costs of prescribing in contrast to the other groups, e.g. percentage rise in prescribing costs in the year after the introduction of the scheme -7.9%, +1.2% and +7.3% respectively, (P < 0.05) for savers, modest overspenders and large overspenders respectively. This effect was short lived however and was gone by the third year of the study.
                The financial incentives had a marked effect on prescribing volume and cost on some practices who could achieve targets and hence incentive payments. The incentives had little effect on high spending practices. Such incentive schemes need careful evaluation if they are not to become perverse to the good health of patients. In this paper empirical evidence for substitution processes caused by the budget for drugs prescribed by office-based physicians is provided. Due to substitution processes in a natural experiment the number of referrals and hospital admissions increased significantly after the introduction of a drug budget in Germany. This leads to additional direct and indirect cost for the health care system. An earlier paper published in this journal suggested that fundholding practices in Lincolnshire had managed to constrain the growth in their prescribing costs more successfully than had non-fundholders, largely on the basis of restricting the number of items prescribed per patient. At that time, insufficient data were available to explore the impact of a change in status from non-fundholding to fundholding on prescribing behaviour.
                Time-series prescribing data for the fourth-wave of Lincolnshire fundholders are analysed, and comparisons are made between this group, non-fundholders and the fundholders of the earlier waves.
                In their first year of fundholding, fourth-wave practices adopted the prescribing strategies employed previously by existing fundholders, namely, reductions in the number of items prescribed per patient and substantial increases in generic prescribing. The hypothesis that prospective fundholders inflate their prescribing budget before attaining fundholding status is not generally supported by the Lincolnshire data. Evidence is presented which suggests that the prescribing cost economies accruing to fundholding status may be short term.
                With the acquisition of fundholding status, the structure of incentives facing practices changes. Our results suggest that, with respect to prescribing, practices adjust rapidly to the new incentive structure. To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners.
                Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995.
                District health authority in south-west England.
                10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients.
                Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times.
                In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5.
                Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients. To compare general practitioners' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991.
                Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992.
                Oxford region.
                Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices.
                Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms.
                Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%).
                Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect.
Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.