Total purchasing, community and continuing care: lessons for future policydevelopments in the NHS

The introduction of total purchasing pilots (TPPs) into the National Health Service (NHS) gave general practitioners (GPs) significant new opportuniti es to take responsibility for the development of community and continuing c are (CCC) services. Based on five case studies of TPPs involved in developi ng CCC this paper asks three questions: (1) to what extent were the TPP's i nvolvement in CCC informed by an awareness of CCC policy?; (2) were TPPs in volved in joint commissioning to develop integrated purchasing or provision which was informed by population based needs assessment?; (3) were TPPs se eking to involve users, carers and voluntary agencies in their plans? The f indings indicate that TPPs showed little awareness of national or local pol icy for CCC, although their project initiatives did address some of the pol icy issues (in particular a recognition of the need for joint working at th e practice level). At the time of fieldwork, four of the case study TPPs ha d begun to investigate the potential for integrated purchasing, and three o f them had relatively sophisticated models of both horizontally and vertica lly integrated provision of care. However, the TPPs developments were not b ased on systematic population based needs assessment. The paper concludes t hat there is potential for the primary care led groups proposed in the rece nt white papers in England, Scotland and Wales to improve integration of ca re both horizontally and vertically. However, they may need policy guidance and push to: encourage them to put CCC high on their agenda for action; to work with people with expertise in population based, prevention focused, n eeds assessment; and to find innovative ways to include users, carers and v oluntary agencies. Incentives or levers (such as control over budgets) may be needed to promote joint working between staff in different agencies.