Measuring progress towards a primary care-led NHS

Background. The push towards a 'primary care-led' National Health Service ( NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practi tioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent S cottish Health Service White Paper and its English counterpart. Aim. To consider three questions in relation to this policy goal. First, do es the evidence base support the changes? Secondly, what is the scale of th e changes that have occurred? Thirdly, what are the barriers to the develop ment of a primary care-led NHS. Method. Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary ca re. Total NHS revenue expenditure for the 15 Scottish health boards was gro uped into four blocks or 'programmes': primary care, secondary care, commun ity services, and a residual. The study period was 1991/2 to 1995/6. Expend iture data were supplied by the Scottish Office. Results. Ambiguity of definitions and the absence of good data cause method ological difficulties in evaluating the scale and the appropriateness of th e shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation bet ween care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth mone y rather than a 'shift' from secondary care. In addition, the impact of GP- led commissioning is variable but limited Conclusion. General practitioners' (GPs') attitudes to the policy suggest t hat progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the s hift on the part of GPs, suggest that this is a policy objective that may n ot be achieved.