Does GP fundholding affect the use of tertiary services in the UK?

Since 1991, general practitioners (GPs) in the UK have been allowed to manage part of the NHS funds allocated for the secondary care of their patients. This has included outpatient consultations, pharmaceuticals, community services, and elective surgery. Despite the growing body of research on the impact of such GP fundholding,' there have been no reports on its effect on the use of tertiary services. This is partly because the purchase of most of the services provided by tertiary centres has remained the responsibility of health authorities. There has, however, been one important exception, that of elective surgery. And if total purchasing (in which GPs control funds for all secondary and tertiary services used by their patients) were to be widely adopted, most tertiary services would become dependent on the purchasing decisions of GPs. This is of considerable concern to the providers of these services, who fear that GP fundholding has led to a reduction in demand for coronary revascularization.2 Evidence from other countries of the impact that the method of funding can have on such services seems to justify their concerns.3 4 The objective of this study was to provide an indication of what effect, if any, GP fundholding has had on tertiary services. An ecological study was carried out in which changes in health district rates of coronary revascularization (coronary artery bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA)) were compared with the proportion of the population covered by GP fundholders.