Primary care

Will primary care trusts lead to US-style health care?

Allyson M Pollock, professor. 

Health Policy and Health Services Research Unit, School of Public Policy, University College London, London WC1H 9EZ

allyson.pollock{at}ucl.ac.uk

The use of private finance in primary care premises has seen the entry of commercial property developers and for-profit healthcare companies, paralleling developments in the NHS hospital sector.¹ As funding for capital investment in the NHS has become more complex, with the requirement that public-private partnerships generate a mixture of state and commercial revenues, the risks and costs of investment make general practitioners' ownership of premises increasingly unlikely.¹ At the same time, the government's NHS Plan expects a rapid move of general practitioners into a salaried service, the end of independent contractor status, and an increasing role for the private sector.² These changes raise questions about how government policy will affect the control of clinical decision making in managing NHS budgets and the core principles of the NHS. In this article I examine these issues from the perspective of the duties imposed by the NHS Plan on primary care trusts, which are the new NHS structures for health and social care, and show how the Health and Social Care Bill 2000 could move the United Kingdom towards a US-style health care system.

	Primary care trusts and care trustsNHS trading bodies

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The Health Act 1999 introduced primary care groups and primary care trusts. Primary care groups and trusts³ hold unified, cash limited budgets to pay for their patients' use of hospital and community health services, general medical services, and prescribing.⁴ The government intends that primary care trusts will hold around 70% of the entire NHS budget. There are currently 434 primary care groups and 40 first wave primary care trusts in England; a further 124 primary care groups are to become trusts in April 2001.⁵

The Health and Social Care Bill also provides for primary care trusts to become care trusts holding social care budgets under delegated authority from local authorities. Although this has been hailed as a means of integrating health and social care budgets, it means that for the first time a NHS body in England and Wales will have a mechanism and the powers to charge for personal care and hotel costs. This is because health care is funded from central taxation and is free at the point of delivery, whereas personal or social care in England and Wales is partly funded from user charges.⁶ Scotland has decided not to introduce charges for personal care or to implement care trusts, which means that patients in Scotland and England will be treated unequally within the NHS.

The Health Act constitutes primary care trusts as trading bodies required to manage the risks and costs of care.⁷ Like other NHS trusts, their main statutory duties are financial, and they must remain within the resource limits set them and pay a charge on their assets. The NHS Plan has put in place a series of measures that will enable failing truststhat is, those that do not meet their statutory financial targetsto be taken over by private firms or by other trusts. Currently, NHS trusts can generate income only through fees from private patients and funds for commercial research, both of which are restricted by capacity constraints.

In the next sections I explore the cost pressures that trusts face relating to capped budgets, drug prescribing and new technologies, and the use of private finance and the various ways in which they might respond to the requirement to keep within budget.^8-10

	Cost pressures related to capital investment

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The debts incurred using private finance to fund capital investment will present an important new cost pressure. The NHS plan predicts that by 2007 the NHS will become liable for an extra £7bn capital investment using private finance. Although NHS trusts must repay debts from their annual current expenditure, the government has not published the current or future annual revenue implications of using private finance. The only aggregate data relate to the £319m annual rental reimbursement scheme for primary care.

Published data for the £2bn of first wave private finance initiative deals signed by November 2000 show that the annual availability fee and total private finance initiative charge average 12% and 17% respectively of the total capital investment.¹¹ Based on these averages, the annual payments made by trusts for private finance will increase threefold, from £654m annually for schemes signed in November 2000, to over £2.1bn by 2007 (table 1). NHS trusts also have to pay capital charges of £2.4bn to the Treasury on land, buildings, and equipment owned by the NHS. By 2007, NHS trusts will have to find £4.5bn from their annual revenue allocations to service their private finance debts and capital charges. Since trusts are locked into private finance initiative deals for 25-30 years, the escalating cost of private finance will be at the expense of clinical services and patient care unless there is a commensurate increase in funding.^11-13

	Strategies for dealing with cost pressures

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The four potential ways in which care trusts and primary care trusts might deal with cost pressures are listed in the box and discussed below.

Reducing expenditure on premises
Trusts may seek to reduce expenditure on general practice premises. Currently, many general practitioners opting into personal medical services pilots are given a generous baseline budget for practice premises and salary costs, which they negotiate locally. Trusts faced with revenue shortfalls may be tempted to reduce general medical services expenditure on non-ringfenced capital schemes. General practitioners could face the risk of not being adequately reimbursed for their premises, a situation they currently encounter when the payments they make as part of a lease or finance deal exceed the district valuer's market rent valuation. General practitioners will no longer have the same control or ability to negotiate rental reimbursement when trust boards are in place, and for-profit market entrants may make generous offers to buy out general practitioners from their share of ownership.¹ This is not inconsistent with the government's aim of making general practice into a salaried service.

Increasing income from commercial and retail outlets and sale of health care
The procurement of new premises and health centres under public-private partnerships relies on generating new income streams from the provision of social services, housing, and private health care (such as nursing and residential care homes) and from commercial and retail outlets. Many of the new entrants into ownership of NHS premises fund the capital investment raised under the private finance initiative from commercial revenues.¹ There are currently no restrictions on trusts setting up business ventures, and the government has introduced an equity arm to drive the process known as the Local Improvement Finance Trust (LIFT).

Reducing expenditure on NHS care and increasing income from charges
The Health and Social Care Bill allows primary care trusts to generate non-NHS income through user charges by becoming care trusts and holding pooled budgets for health and social care. The most obvious area for the introduction of charges is the intermediate care sector. This is the new care sector identified by the government to reverse the decline in NHS capacity resulting from decades of closure of NHS beds and services in long term care, rehabilitation, and recovery.

Maximising income by selecting patients for case mix

Cherry picking
Primary care trusts have a built-in incentive to select patients, known in the United States as cream skimming or cherry picking. The NHS covers all patients in the United Kingdom. However, because general practitioners can choose their patients, trusts will have the potential to select patients on the basis of risk either by encouraging private health cover or by selecting lower risk groups. For example, walk-in centres and NHS Direct provide trusts with a mechanism for identifying high risk patients and selecting them out. Trusts in prosperous areas will have a built-in advantage as well as the ability to promote greater use of private insurance.

Risk adjusted funding or capitation
Unlike health authorities, primary care trusts are not reimbursed on the basis of geographically defined populations but on the basis of practice lists. This marks a fundamental shift in the principle of resource allocation and risk pooling over geographical populations. The change could come to be seen as a major opening for a move to an insurance based system.

	Will public-private partnerships take us down the American way?

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In September 2000 the Institute for Public Policy Research working group on public-private partnerships advocated transferring NHS and clinical staff to the private sector and allowing health care companies to run primary care trusts.¹⁹ Pilots are already up and running, with NHS trusts subcontracting acute and intermediate care services and pathology services to private hospitals. Clinical services under these contracts are being privatised.⁶

The government presents its NHS Plan and the Health and Social Care Bill as a move towards greater integration coupled with long overdue investment. The principles are to be applauded, but the reality is different. There is the spectre of US-style health maintenance organisations, to which the new structures of the NHS conform. Like health maintenance organisations, primary care trusts will increasingly operate in the market as trading bodes. Clause 4 of the Health and Social Care Bill enables the secretary of state to transfer public funds to the private sector as direct grants or loans, and it also allows the private sector to operate and run clinical and social care services on his behalf. Care trusts will be responsible not just for the risks and costs of care but also for reconciling the competing objectives of meeting the returns required by shareholders and public health needs.

As with health maintenance organisations, the reimbursement mechanisms of care trusts are being altered in ways that facilitate a shift away from social insurance and universal coverage to personal insurance, user charges, and time limited care. The integration of budgets and responsibilities for health and social care creates the mechanisms and incentive structure for introducing charges for personal care and hotel costs. This, combined with the recent guidance which limits NHS intermediate care to six weeks, means that more patients are likely to find themselves paying for elements of care that they once received free under the NHS.

	Restoring public health principles

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There is still time to ameliorate this policy. Firstly, the government should reaffirm the principle of universality by requiring that care trusts serve, and are reimbursed on the basis of, geographical populations rather than practice lists. This will preclude any tendency to cherry pick and minimise a drift to private health care insurance. Secondly, the central recommendation of the Royal Commission on Long Term Carethat personal social care be provided free at the point of delivery and funded from general taxationshould be implemented (as it is in Scotland). This will make it more difficult to make care a personal responsibility and prevent NHS care trusts from shunting costs to individuals and introducing eligibility criteria for NHS care. Thirdly, commercial activities such as the sale of private health insurance and private health care should be prohibited from any premise in which the NHS pays for care. This would prevent the blurring of the boundaries for responsibility for funding care and conflicts of interest as trusts struggle to meet their statutory financial duties. Fourthly, the bill should remove the statutory financial duties on trusts, including capital charges. It should also abolish the contracting system, which drives market behaviour. Finally, it should establish proper mechanisms for local and parliamentary accountability to reverse the current democratic deficit. Unless the legislation is amended along these lines, Bevan's legacy and the principles of universality and comprehensive care upon which the NHS was founded will be destroyed, and the Health and Social Care Bill will indeed be the last act of the NHS.

	Acknowledgments

Competing interests: None declared.

	References

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1.	Pollock AM, Player S, Godden S. Financing primary care. BMJ 2001;322: linked article same issue.
2.	Secretary of State for Health. The NHS plan. London: Stationery Office, 2000.
3.	Department of Health. The new NHS. London: Stationery Office, 1997.
4.	Majeed A, Malcolm L. Unified budgets for primary care groups. BMJ 1999; 318: 772-776[Free Full Text].
5.	NHS Executive. Primary care trusts. www.doh.gov.uk/pricare/pcts.htm (accessed 6 March 2001).
6.	Pollock AM. Will intermediate care be the undoing of the NHS? BMJ 2000; 321: 393-394[Free Full Text].
7.	House of Commons. Health and social care bill. London: Stationery Office, 2000.
8.	Player S, Godden S, Pollock AM. Well-laid plans. Health Service Journal 1999 Nov 4:28-9.
9.	Pollock AM. Primary carefrom fundholding to health maintenance organisations? NHS Doctor and Commissioning GP 1998 Jul:6-7.
10.	Pollock AM. The American way. Health Service Journal. 1998 Apr 4:28-9.
11.	Department of Health. Expenditure questionnaire 2000. Memorandum to the health committee, NHS resources and activity. London: Stationery Office, 2000.
12.	Department of Health. Departmental investment strategy. London: DoH, 2000.
13.	Health Select Committee. Public expenditure on health and personal social services 2000. Memorandum received from the Department of Health containing replies to a written questionnaire from the committee. London: Stationery Office, 2000.
14.	Trade Partners UK. Sector overview. www.tradepartners.gov.uk/healthcare/profile/index/overview.shtml (accessed 6 March 2001).
15.	Department of Health. Intermediate care. London: DoH, 2001. (HSC 2001/01: LAC(2001)1.)
16.	Ellis R, Pope G, Iezzoni L. Diagnosis-based risk adjustment for medical capitation payments. Health Care Financing Review 1996; 17: 101-128[Medline].
17.	Kronick RT, Dreyfus LL, Zhou Z. Diagnostic risk adjustment for Medicaid: the disability capitation payment system. Health Care Financing Review 1996; 17: 7-33[Medline].
18.	Kuttner R. Everything for sale. Chicago: University of Chicago Press, 1999:143-144.
19.	Institute for Public Policy Research Working Group On Health. PPPs in health: summary of recommendations for commission meeting on 13th September. London: IPPR, 2000.

(Accepted 21 February 2001)