Health and Social Care in the Community 7(6), 394 – 407 394 © 1999 Blackwell Science Ltd Abstract The introduction of total purchasing pilots (TPPs) into the National Health Service (NHS) gave general practitioners (GPs) significant new opportunities to take responsibility for the development of community and continuing care (CCC) services. Based on five case studies of TPPs involved in developing CCC this paper asks three questions: (1) to what extent were the TPP’s involvement in CCC informed by an awareness of CCC policy?; (2) were TPPs involved in joint commissioning to develop integrated purchasing or provision which was informed by population based needs assessment?; (3) were TPPs seeking to involve users, carers and voluntary agencies in their plans? The findings indicate that TPPs showed little awareness of national or local policy for CCC, although their project initiatives did address some of the policy issues (in particular a recognition of the need for joint working at the practice level). At the time of fieldwork, four of the case study TPPs had begun to investigate the potential for integrated purchasing, and three of them had relatively sophisticated models of both horizontally and vertically integrated provision of care. However, the TPPs developments were not based on systematic population based needs assessment. The paper concludes that there is potential for the primary care led groups proposed in the recent white papers in England, Scotland and Wales to improve integration of care both horizontally and vertically. However, they may need policy guidance and push to: encourage them to put CCC high on their agenda for action; to work with people with expertise in population based, prevention focused, needs assessment; and to find innovative ways to include users, carers and voluntary agencies. Incentives or levers (such as control over budgets) may be needed to promote joint working between staff in different agencies. Keywords: community and continuing care, general practice, integrated provision, joint commissioning, total purchasing Accepted for publication 10 December 1998 Blackwell Science, Ltd Total purchasing, community and continuing care: lessons for future policy developments in the NHS Sally Wyke PhD 1 , Susan Myles MSc 1 , Jennie Popay PhD 2 , Judith Scott MA 1 Andrea Campbell MPH 3 and Jeff Girling PhD 4 On behalf of the Total Purchasing National Evaluation Team (TP-NET), 1 University of Edinburgh, Primary Care Research Group, UK, 2 University of Salford, Public Health Research and Resource Centre and National Primary Care Research and Development Centre, UK, 3 Sefton Health Authority, Director of Community Care, UK, 4 University of Manchester, Health Service Management Unit and National Primary Care Research and Development Centre, Manchester, UK Correspondence Sally Wyke Primary Care Research Group Department of General Practice University of Edinburgh 20 West Richmond Street Edinburgh EH8 9DX UK E-mail: sally.wyke@ed.ac.uk Introduction The gap between rhetoric and reality within the NHS has been nowhere more evident than in the field of community care. As Richard Titmuss pointed out some 40 years ago: In the public mind, the aspirations of reformers are trans- muted by the touch of a phrase, into hard-won reality … and what of the everlasting cottage-garden trailer, ‘Community Care’? Does it not conjure up a sense of warmth and human kindness essentially personal and comforting, as loving as