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Reform of the National Health Service in England will increase power and responsibility for family doctors. They will have a larger role in planning and buying health care including control of substantial budgets. This article examines the likely implications of the proposed reforms for primary care, and in particularly for family doctors. This article considers the effect of the new clinical role in commissioning health care, changes to the accountability structures, and the effect on competition and integration within health services. It also considers the effect of new financial incentives and the possibility of creating conflicts of interest.

Objectives: To describe the current use of external support by commissioners in the English NHS; assess what impact it is having; explore the factors influencing effectiveness; and draw out the implications for the future of NHS commissioning., Methods: (1) Two national surveys of primary care trust managers. (2) Qualitative interviews and focus groups with representatives of 12 firms providing support services to commissioners. (3) Focus groups in three primary care trusts and interviews with representatives of two strategic health authorities (SHAs)., Results: The majority of survey respondents reported using external support (89% in 2010). Satisfaction levels were reasonably high, with most rating the service received as excellent or good. Perceived impact in the case study sites was mixed, but benefits were reported in a number of areas. There were cases where external support had not achieved its goals. Several factors contributed to success or failure, including difficulties around procuring external support; building effective working relationships; and implementing the ideas generated by external partners. There was evidence that commissioners do not always use support in a way that takes full advantage of the skills existing in external organizations. There was also some evidence that poorer performing organizations may be less successful in using external support effectively., Conclusions: External support can play a role in improving the quality of commissioning. However, certain pitfalls must be avoided if it is to be used effectively. The role of external support will evolve (and may expand) as commissioning responsibilities are transferred to general practice consortia.

Background: All modern healthcare systems need to respond to the common challenges posed by an aging population combined with a growing number of patients with (complex) chronic conditions and rising patient expectations. Countries with 'stronger' primary care systems (e.g. the Netherlands and England) seem to be better prepared to address these challenges than countries with 'weaker' primary care (e.g. USA). The role of primary care in a health care system is strongly related to its organisation and funding, thus determining the starting point and the possibilities for change., Method: We selected the Netherlands, England, and USA as examples for the diversity of approaches to organise and finance health care. We analysed the main problems for primary care and reviewed strategies and practice models used to meet the challenges described above., Results: The Netherlands aim to strengthen prevention for chronic diseases, while England strives to improve the management of patients with multimorbidity, prevent hospital admissions to contain costs, and to satisfy the increased demand of patients for access to primary care. Both countries seek to reorganise care around the patient and place their needs at the centre. The USA has to provide sufficient workforce, organisation, and funding for primary care to ensure better access, prevention, and provision of chronic care for its population. Strategies to improve (trans-sectoral) cooperation and care coordination, a main issue in all three countries, include the implementation of standards of care and bundled payments for chronic diseases in the Netherlands, GP commissioning, federated and group practice models in England, and the introduction of the Patient-Centred Medical Home and accountable care organisations in the USA., Conclusion: Organisation and financing of health care differ widely in the three countries. However, the necessity to improve coordination and integration of chronic disease care remains a common and core challenge., (Copyright © 2011. Published by Elsevier GmbH.)

Primary care trusts can be torn between the need for critical mass and the danger of losing local vision and ownership; mergers are politically unpopular and fraught with difficulty. A review of Trafford South PCT stakeholders enabled a range of organisational models to be tested. The result was the creation of a 'joint and integrated management structure' for the two Trafford PCTs.

Primary care trust commissioning is not advanced and there is little evidence of PCTs influencing hospital services. Any further NHS reorganisation would hamper the development of commissioning. PCTs need to engage more GPs in the task of commissioning services. PCTs' ability to move work round on a cost per case basis should strengthen their hand in commissioning from hospitals.

Primary care in the UK has been the subject of numerous changes and reorganizations since 1990. Each innovation in organization, with the exception of fundholding, has been the subject of evaluation. However, the complexities of some innovations make the evaluation process problematic and this is further complicated by the trend towards central policy decision making being subject to local interpretation and implementation, by means of simultaneous devolution and centralization. This paper discusses the challenges and problems posed by attempting to evaluate these new organizations, particularly with regard to whether or not they can be considered to be "successful". It draws specifically on the national evaluation of the total purchasing pilots and indicates how the findings can be applied to primary care groups.