General practitioner commissioning in the English National Health Service: continuity, change, and future challenges

Int J Health Serv. 2008;38(4):717-30. doi: 10.2190/HS.38.4.h.


General practitioner fundholding (GPFH) in the English National Health Service was abolished by the Blair administration in 1999 amid concerns that it was inequitable, helped to foster a "two-tier" health service, and incurred high transaction costs. In April 2005 in an apparent volte face, the Blair government reintroduced delegated budgets to individual GP practices under the banner of Practice Based Commissioning (PBC). As PBC bears many similarities to GPFH it is timely to take stock of evidence-based policy lessons from the earlier initiative in the NHS. Based on a review of the latest empirical evidence, the aim of this article is to help inform the development and implementation of PBC by identifying the policy lessons of GPFH. To do this the discussion focuses on three main areas: it (1) reviews key ideas and conceptual frameworks for understanding stability and change in health systems; (2) summarizes the origins and evolution of primary care commissioning in the NHS; and (3) examines the latest literature and empirical analysis on the impact of GPFH and assesses the success of GPFH in meeting a range of health policy objectives. The article concludes with an examination of the policy implications of the present review and a look forward at the emerging research agenda.

Publication types

  • Review

MeSH terms

  • Budgets
  • Contract Services
  • Family Practice / organization & administration*
  • Financing, Government / legislation & jurisprudence*
  • Health Care Reform / legislation & jurisprudence*
  • Health Plan Implementation
  • Health Services Research
  • Healthcare Disparities
  • Humans
  • Politics
  • Program Development
  • Socioeconomic Factors
  • State Medicine / organization & administration*
  • United Kingdom