Fundholding: learning from the past and looking to the future.

Australian trials of healthcare initiatives that included fundholding models have not produced convincing quantitative evidence of health gains, but there is qualitative evidence of improved patient well-being and significant changes in service mix, which may produce longer-term health gains. Fundholding is most likely to improve patient outcomes when implemented within a broader healthcare initiative that has the potential to be more effective if financed outside existing funding structures. The most appropriate fundholder organisation depends on the nature of the initiative and the type of stakeholder engagement required, but technical and organisational skills will always be needed for balancing financial viability and additional patient services. Stakeholders' willingness to engage in fundholding depends on the anticipated budget impact, how they will use the savings generated, and whether workforce needs will be fulfilled. Before including fundholding in healthcare initiatives, there must be realistic prospective analyses and community debate. Monitoring and evaluation frameworks must also be in place to provide ongoing evidence of quality of care, health and well-being outcomes and financial implications for fund contributors.