Family doctors have regrouped into new professional organisations to meet the challenge of primary care groups. Lyn Whitfield examines their differences
The launch of the National Association of Primary Care added bite to an otherwise routine meeting for the leaders of the NHS Primary Care Group Alliance last week.
Health minister Alan Milburn found time to attend the launch, formed by a merger between the National Association of Fundholding Practices and the Association of Independent Multifunds.
He was not at the lower-key launch of the PCG Alliance, successor to the National Association of Commissioning GPs, at a Euston hotel two months earlier.
Alliance chief officer Michael Sobanja and chair Michael Dixon say they 'didn't think about' inviting him. But they were plainly surprised the minister had apparently courted an organisation headed by former fundholders' leader Rhidian Morris.
'NAFP and AIM were born out of a previous government's health policy,' said Dr Dixon in a statement responding to the launch.
'The NACGP stood alone for many years, an underdog that was never supported on an ideological level by the government nor on a financial one by the taxpayer.
'The advertised presence of the minister for health at the launch of a 'new' NAFP/AIM looks suspiciously like the strong looking after the strong.'
The hint of bitterness is understandable. Dr Dixon, a Devon GP working in an eight-handed practice covering 150 square miles, was a member of Devon's local medical committee when the Conservatives' NHS reforms were introduced in 1990. 'My first thought was that the reforms were sensible - separating purchasing from providing did make the service more accountable,' he says.
'But I never understood fundholding because it was all about money and secondary care, rather than improving primary care. I also felt the therapeutic role of the doctor was undermined when patients knew he held the budget for their treatment.'
Dr Morris was a member of Devon LMC at the same time. But while he embraced the reforms, Dr Dixon helped to form the Mid-Devon commissioning group.
It negotiated with local trusts to make sure fundholders did not get preferential treatment and worked with its 'wonderfully supportive' health authority on a range of population-based projects. 'I think it was true to say there was no two-tierism in our area until the very end, when our trust ran into financial trouble and had to close to non-fundholders' patients,' says Dr Dixon. 'Fundholders had access throughout those six months. It shows how unfair the system was.'
When Labour was elected, the NACGP's leaders thought their time had come. Press spokesman Ron Singer told HSJ last June he 'could not understand' why reporters wanted to talk about fundholding, when it was 'yesterday's news'. But the PCG Alliance has since received little overt government support. Backing from 'ethical pharmaceutical companies' has allowed it to start producing 'support packs for PCGs' and it is looking for offices.
Mr Sobanja and Dr Dixon continue to meet at the hotel where the organisation was launched. The PCG Alliance is also lobbying hard for investment in IT equipment for non-fundholders, who risk being at a disadvantage when PCGs go live next year.
But Dr Dixon accuses Mr Milburn of doing 'absolutely nothing to bridge the disinvestment gap' between the GPs who fought the Tories' policies and those who fought Labour.
There is also a growing suspicion that fundholding might not be quite as dead as it seemed last year. Dr Dixon believes the NAPC wants it to continue.
'It vows to 'strongly promote the right for practices to have a budget at practice level if they wish',' he says. 'That sounds like fundholding under another name.
'The focus of commissioning (in PCGs) must be on populations and not patients at the practice level. The NAPC and the government must make their respective positions clear - does NAPC now support the co-ordinated and equitable planning, procurement, provision and review of services for a community? And is the government still opposed to practice-level budget holding?'
In 1990, Mr Sobanja was director of purchasing and planning for Northampton HA, and thus in charge of implementing the Conservative reforms locally. 'People were running around doorstepping GPs to try to get them involved,' he says. 'I thought there had to be a better way to do it.'
The Northampton commissioning group was the result - another organisation that worked with the HA and trusts without undue reliance on market mechanisms.
'We never saw contracts as an end in themselves - they were there to set the agenda,' says Mr Sobanja, who feels this was a practical approach in a rural area, where hospitals were too far apart to compete 'properly'.
He and Dr Dixon both oppose making PCGs 'top-down' organisations. Yet a number of commentators, including York University's Professor Alan Maynard, believe the whole point of PCGs is to manage GPs 'to hell and back'.
Dr Morris also sees PCGs as a 'fundholding model' at any level, despite the commissioning language used about them in The New NHS white paper.
Mr Milburn's presence at the launch of the NAPC last week could be thought to support this.
But the PCG Alliance does not believe it is how PCGs will evolve. 'In the long run, GPs are great guerrilla fighters and they can bust any system,' Dr Dixon says. 'These groups will not work unless everybody goes along with them.'
It will be interesting to see which of the new organisations is right.