The state, the NHS, and general practice.

There has been much discussion about the changes introduced by the Government in 1989 in the hospital sector of the British National Health Service. In contrast, the changes in the primary health care sector have gone largely undebated. This paper's contention is that these may turn out to be equally if not more important. The changes mean that general practice doctors are now subject to greater accountability than ever before through new management and finance systems, while new pay structures have shifted the emphasis of the service itself towards preventive health interventions. The new fundholding scheme, which allows some practices to apply to hold their own budgets and buy services for their patients, could alter the balance of power between the hospitals and general practice. In all, the emphasis of Government policy has been placed squarely on better pay for more and better work from general practice doctors while at the same time enabling patients to choose more freely where to register for primary health care. The changes in general practice could therefore achieve radical and permanent changes in the structure of the National Health Service and in the relationship between the State and the profession.