To have and to hold

Even a£266m hand-out from health minister Alan Milburn was not enough to dampen down the burning issue at last week's NHS Primary Care Group Alliance conference.

The relationship between ex-fundholding practices and the rest dominated the Blackpool event, although delegates gave a grudging welcome to the announcement of primary care's share of the£1.2bn NHS modernisation fund.

Mr Milburn tried to reassure delegates that the money would be distributed more evenly under the new system than under fundholding.

'Part of that cash comes from the resources that would have gone to just half of GPs through the practice fund management allowance for fundholding.

'Instead it is being used to support 100 per cent of GPs through the new PCGs,' he said.

But the conference was more concerned about the news that practices would be able to hang on to half of all savings made in PCGs.

The minister said any future savings would be split '50-50' between the practice and the PCG - a division that delegates feared would recreate the inequalities of fundholding.

PCG Alliance chair Michael Dixon said the 'old system' of fundholding 'threw up inequities in the treatment of patients' by allowing fundholding practices to invest money in their services that was denied to non-fundholders.

'If primary care is to become the bedrock of the modernised NHS, these funds must be directed to the areas of most need,' he said. 'We must seize the opportunity to create a level playing field as quickly as we can.'

But Mr Milburn insisted that his department had 'looked very carefully at previous commissioning models' and the 50-50 split between practice and organisation 'was the right balance'.

North London GP Ian Fletcher said the split risked damaging the 'healing process' of bringing non-fundholders and fundholders together in PCGs.

It 'would allow the very division we have been talking of to be maintained'.

The minister stressed that 'we don't start from the position that we would like to start from' and that GP fundholders were 'legally entitled to those savings made under the scheme'.

'Exactly the same considerations apply to practice-level incentives' in the new system, he added, because 'it is very important that people are brought into the system'.

But Mr Milburn promised: 'We are not going back to the old incentives behaviour' of fundholding.

'We will expect to see savings spent in a way that is consistent with the health improvement programme,' he said.

Spending on GP premises would have to be 'consistent with the local primary care development plan', he added.

That was not enough to reassure the PCG Alliance, an organisation which grew out of the National Association of Commissioning GPs.

Executive committee member Ron Singer, a GP in north London, said: 'There has to be risk-management in terms of a war between GPs.'

Mr Milburn 'wants to enshrine fairness but actually what he has enshrined is inequality between practices', he claimed.

Dr Singer accepted the minister's point that there had to be practice- level incentives to bring reluctant GPs into the new PCG scheme.

But he said he was 'keen to see more money being targeted to practices that are locked out of the process', those with poor premises and with little access to IT because they hadn't had access to fundholding resources.

Dr Singer spelled out the feelings of many PCG Alliance's members when he said: 'Practices like mine have suffered because they didn't go fundholding.'

And Mr Milburn's admission that 'some of the most deprived communities in the country have had the greatest difficulties in developing high-quality primary care services' did nothing to allay his fears of past inequalities being repeated.

It was not just ex-fundholders whom delegates saw as a threat to their unified budgets under PCGs.

Social services are guaranteed one representative on each PCG board and some GPs are concerned about the implications for NHS resources.

Huddersfield GP Bert Gentle warned that in the new system, social services 'have two bites of the cherry'.

'They have their own budget and access to PCGs' but PCGs only have access to their own.'

But Ian Winter, Northamptonshire director of social services, defended his colleagues, saying: 'I don't accept that is the case.'

Instead the reverse would be true, he said.

If PCGs got 'the right representatives from social services' on their boards, 'I believe PCGs will get greater access to community care and childcare resources than ever before,' he said.

GPs 'will be able to influence the spread of social services costs and get access to pooled budgets', he added.

But Mr Winter did admit there was a risk in greater financial links between health and social services.

'At the end of the day when the budgets go awry, directors of social services centralise budget control,' he pointed out.

And decentralised groups such as PCGs 'could be constantly undermined' unless some solution was found.