Integration into the NHS

    Over the last decade or so there have been major organisational and structural changes within primary care in the NHS. The late 1980s brought the introduction of fundholding (1989), and more recently primary care groups (PCGs) have been introduced in England (Local Health Groups in Wales, and Local Health Care Co-operatives in Scotland and Northern Ireland) (1999), which will eventually develop into primary care trusts (PCTs). One of the aims of  fundholding was to give GPs greater awareness of, and responsibility for, their use of secondary care services, and the change was intended to lead to improved cost containment, cost-effectiveness, quality of care, patient choice and empowerment. There is consistent evidence that fundholding practices provided better access to secondary services, greater development of new practice-based services for patients, and reduced waiting lists (Samuel, 1992; Dowling, 1997). The provision of CAM was also facilitated by GP fundholding, since those fundholding practices were able to use the staff element of their budget to employ CAM practitioners. Non-fundholding GPs, on the other hand, were able to use their ancillary staff budget for this purpose, but at the expense of another member of staff. Local health commissions and authorities have sometimes used money for R & D or for waiting list initiatives to finance CAM provision (Zollman and Vickers, 1999).

    With the NHS reforms in April 1999, uncertainty regarding the position of CAM in the NHS has emerged. PCGs are subcommittees of Health Authorities (HAs) and are dependent on them for some commissioning support. Their responsibilities include (NHSE 1998):

• to improve the health of, and address health inequalities in, their communities
• to develop primary care and community services (with an emphasis on reducing variability of services, developing clinical governance and increasing integration of primary and community care services)
• to advise on, or commission directly, a range of hospital services.