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Monthly prescribing behaviour is assessed over a 3‐year period, 1 April 1992 to 31 March 1995. Total monthly number of items prescribed and overall net ingredient cost are analysed for 263 general practices, serving the 1 million residents of Birmingham, UK. Patients aged over 65 years play an important role in elevated prescribing activity. Practice composition varies considerably between training and non‐training practices, and between fundholding and non‐fundholding practices. Accounting for these differences, fundholders expend less and prescribe fewer items than their non‐fundholding counterparts. This is observed against a steady increase in prescribing activity over the study period. There are, however, marked downward shifts in both the number of items prescribed and overall monthly expenditure occurring with every new wave of fundholding. The magnitude of these changes raises doubts about the efficacy of the transition to fundholding and the impact of such large changes upon patient care.

Fundholding (the opportunity to hold a budget at practice level) has given general practitioners (GPs) purchasing power for medical services within the reformed UK National Health Service (NHS). This new purchasing power equates to financial leverage with the NHS consultants in hospitals. Argues that fundholding is presented as an opportunity for GPs to engage in a “turf battle” with the hospital consultants without this battle becoming publicly visible. Fundholding as an accounting‐based intervention masked the nature of the professional challenge which GPs launched against the consultants and, hence, allowed territorial claims to be renegotiated through the medium of contracting. This circumvented the damage to medical professional ideologies which would have ensued if intra‐professional conflicts had become overt. The empirical study which is referred to indicates that GPs are using contracts to improve processes of case management at the hospital interface (an area where consultants have failed to communicate with GPs) and to have an input into the setting of quality standards within the hospitals. The increased financial flexibility conferred through holding budgets is also enabling GPs to expand in‐house services for primary care. Theorizes the changing power relations between GPs and consultants through exploring four dimensions of intra‐professional differentiation: task specialization; client differentiation; organization of work; and career pattern. Concludes that budgets have constituted a catalyst for professional development through reconnecting the monetary bonds between the polarized professionals in British medicine. This study indicates that, as fundholding progresses, the boundary between primary and secondary care is becoming blurred; that lead fundholding GPs are being managerialized; and that the purchasing dialogue between the GPs and the Trusts is marginalizing the role of the Health Boards (bodies which had previously held sole responsibility for the co‐ordination and delivery of health care but which now have a more limited purchasing/commissioning role).

The prevalence of rather negative, or at best mixed, attitudes of doctors towards participation in management has been reported in several previous research studies. This paper adds to that growing empirical literature, but complements most of the previous studies by focusing on general medical practitioners in primary care rather than on doctors in secondary care settings. The focus for the study were doctors who had agreed to undertake the lead partner role in the now‐defunct general practitioner fundholding initiative within the UK National Health Service. The findings indicate widespread reluctance but the presence of a minority of enthusiasts, which resonates with previous studies of secondary care settings. A finding of potential significance for future research and practice was that some doctors who were initially reluctant became more keen on undertaking a management role once they had experienced it.

Describes the views of practice managers in 30 fundholding practices in the Northern Region concerning their role in the scheme. A self‐completion questionnaire was mailed to practice managers and general practitioners containing questions designed to elicit their views about changes in relationships inside and outside the practice; their level of involve‐ment in various aspects of fundholding; and the costs and benefits of the scheme. A total of 30 first‐, second‐, and third‐wave fundholding practices in the Northern Region, June 1993 were involved. Replies were received from 22 practice managers (73 per cent) and 83 general practitioners (49 per cent). Concludes that although fundholding has increased the nature and volume of the workload of practice managers, these changes do not appear to be causing any tensions between managers and clinicians. At the moment fundholding extends the support role of practice managers and does not alter existing authority relations in practices.

This paper explores the resistance strategies of organisations to unwanted changes. It is concerned with the way satellite organisations are created to provide a counter force to environmental disturbances such as changes introduced in the context of what has come to be called New Public Management. Its particular focus is with the attempt to develop and institutionalize external, “public” forms of resistance rather than undertake more internal, “private” forms. The specific empirical focus is general medical practice in the UK, where commissioning groups were formed as an alternative to GP fundholding. To help analyse this empirical detail we draw insights from Habermas’s model of society, organisational change theory and institutional theory. In the process the paper not only amplifies the empirical reactions of GP practices in the UK but also uses this empirical detail to develop the nature of this theoretical base by adding new dimensions concerning organisational resistance.

Examines the relationships between the macro‐, meso‐, and micro‐levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co‐operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro‐level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso‐) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their “market share”. PCGs and LHCCs represent a shift back to the meso‐level in service planning and purchasing. As such there is a risk that the micro‐level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.

Reports a study of fundholding in general practice in the Northern Region and notes that although fundholding may have changed the role of practice managers and some general practitioners, the structure of authority remains unaltered. It appears that decision making remains the prerogative of the clinical partners and reliant on the establishment of consensus as the decision‐making approach. Notes that a key feature of fundholding was to enable general practices to develop as small businesses, formulating business plans and setting up management systems supported by computer technology. However, the practices explored within this particular study appear to be working well within the new system despite the continuation of traditional approaches. The outcome in the long term remains to be seen.

Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995‐1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence‐based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically‐driven policy or they will resist it.

Aims to assess the level of agreement between priorities of service provision in 20 discrete clinical areas, as laid out in a district health authority (DHA) purchasing plan, and the views of GPs in the catchment area of that authority and to test for a statistically significant difference between the views of fundholding and non‐fundholding GPs. A 74 per cent response rate was achieved, and analysis suggested that local GPs′ views were broadly in line with their DHA strategy, and that a significant difference existed between the views of fundholders and non‐fundholders in only one treatment area, namely that of lithotripsy. Concludes that the postal questionnaire is a cheap and easy method of assessing the views of GPs on prioritizing issues. As yet there is little difference between fundholding and non‐fundholding GPs in this area of decision making.

Considers the changes which are being implemented in primary care, and the patterns which are now beginning to emerge. Examines the changing context within which practices now function (both political and managerial), and considers the power which GPs are beginning to exert, as well as the impact which they may have on the interface between primary and secondary care. Examines the systems being developed for assuring quality in general practice. Predicts an explosion in the need for appropriate information for management and for medical audit in UK primary care, because the context within which general practitioners (GPs) deliver primary care in the NHS is changing rapidly. It is only now becoming evident that this turbulence may well offer major new opportunities to GPs, as well as permanently altering the balance of power in the NHS between primary and secondary care.