This paper considers the organisational style that a newly elected labour government sought to impose upon the primary health care sector of the National Health Service (NHS) in Scotland. The evidence presented casts doubt on whether such a style was appropriate: the conditions for the reforms’ success probably never existed. In particular the relationship between two powerful groups involved in the delivery of primary care services, namely health care managers and GPs, was characterised by a lack of trust. Yet trusting relationships were necessary for the successful operation of a network-style organisation that the 1997 reforms sought to introduce; the government had hoped that such a network-style of organisation would result from a restructuring of primary health care resource allocation procedures. This paper builds upon research about the effects of earlier reforms to primary health care in the 1990s which suggested that changes as a result of the introduction of new working practices actually eroded the relationship of trust between health care managers and GPs.

The current paper proceeds with a section outlining the background to the 1997 reforms by highlighting the effects of previous changes to primary health care during the 1990s; it presents the government’s purported rationale behind the changes which they introduced in 1997. It also outlines the management structure that operated in primary health care in Scotland as a result of the reforms. In light of the fact that the rhetoric of the 1997 reforms emphasised an organisation operating in a spirit of partnership and trust, the third section reviews the existing literature which explores the concepts of trust and distrust. This section also briefly outlines the aims of the research undertaken and the methods employed in the study. The fourth section summarises the findings of interviews that were conducted; it analyses these findings in section five within the context of the literature review presented in the paper. The concluding section of the paper suggests that the 1997 primary health care resource allocation model was doomed to fail from its inception as the necessary elements of trust and partnership between powerful actors in the system were not present and therefore this model, which has since been replaced, was never truly viable.

2. Background

Between 1948, when the NHS was established in the UK, and 1990, general practice received very little attention from policy makers and remained virtually untouched (Jacobs, 1998). However, during the 1990s several reforms and changes took place in the sector. In 1991, a new contract between GPs and the government was introduced and in 1992, GP fundholding was brought into primary care as part of the wider market-led NHS model. It was the pseudo-market NHS organisation which the new labour government’s reforms of 1997 sought to dismantle and replace with a network-style organisation.

Laughlin, Broadbent, and Shearn (1992) undertook a study of past government reforms; specifically, they examined the effect of the 1990 contract on the delivery of primary health care by GPs. They noted that GPs resisted changes to their relationship with NHS managers who became responsible for overseeing that the government’s requirements of GPs were satisfied. Harrison (1991) felt the role of health service managers had previously been a diplomatic one, working to solve the problems of their particular organisations rather than influencing doctors and their practices. GPs maintained that the contract’s requirements undermined their professionalism (Laughlin et al., 1992). Doctors did not feel that their practices had been lacking, or that they had failed in their obligation to provide general medical services to the society that they served. They therefore saw this first attempt to introduce some uniformity into primary care as a “bureaucratic nuisance… [resulting from a]… breakdown in trust” (Laughlin et al., 1992, p. 147); the new contract was met with a great deal of hostility and resistance from general practitioners.

However, Scottish GPs who took part in the optional fundholding scheme viewed this reform far more favourably. Compared to their English counterparts, practices in Scotland took longer to apply for fundholding status. This was, in part, due to the fact that the mean list size in Scotland was smaller than the UK average. However, as the minimum required list size was gradually reduced, the uptake of the scheme increased in Scotland and by 1996 Scottish fundholding practices totalled 121 (Lapsley, Llewellyn, & Grant, 1997). The Scottish fundholding experience was different to the situation that developed in England as a result of the scheme. Most Scottish hospitals are situated some distance from a similar facility and, as patients tended to be unwilling to travel long distances from their homes for their required hospital treatment, the competitive market that developed in England did not occur amongst providers of Scottish health care. A study conducted by Lapsley et al. (1997) presented evidence that, in Scotland, a positive result of the pseudo-market contracting mechanism was the improvement of care management at the interface of primary and secondary care. Lapsley et al.’s findings indicated that although GPs had attempted to make improvements to their communication with hospital consultants for many years prior to the introduction of fundholding, their efforts had never resulted in changes to practice. However, flexing the financial “muscles” that fundholding conferred on GPs, in particular their ability to withhold payments to secondary care providers, had resulted in certain improvements in hospitals’ services such as the timeliness of discharge letters to GPs and of the notification of a patient’s death in hospital. Another direct result of fundholding was the advent of locality purchasing which gave non-fundholding GPs the opportunity to join together to present their views on service purchasing strategies to the health board. Lapsley et al. (1997) suggested that the success of this form of local commissioning was probably due to the fact that when a practice made the decision to become fundholding the health board overall budget was reduced. It was therefore in the health board managers’ interests to ensure non-fundholding GPs had their needs addressed to the same extent as those of their fundholding colleagues.