Alternatives to fundholding.

The new Labour government in the United Kingdom is proposing to adapt the reforms begun by the last Thatcher government. In particular, it is proposing to abolish the most controversial element--general practitioner (GP) fundholding. It is looking for alternatives. The study reported here followed and evaluated several such schemes. While fundholders use their purchasing power directly to force change by threatening "exit" to another provider, other GPs have evolved ways of influencing decisions--enhancing their "voice." The authors develop a theory to predict the conditions favoring the relative success of exit and voice strategies in health purchasing, and describe alternative GP-based purchasing schemes and the reasons they evolved in six sample districts. In four of these districts and eight practices in each, fundholding and non-fundholding GPs were then asked to describe their intentions and the outcomes of the purchasing process in which they had participated. Four specialties were taken as examples. The authors compare the relative success of fundholders and non-fundholders in achieving their objectives.