Money can't buy you satisfaction
http://www.100md.com
《英国医生杂志》
1 University of Birmingham, Birmingham B15 2RT
Correspondence to: c.j.ham@bham.ac.uk
Organisational differences between the US and UK healthcare systems mean that ideas have to be adapted through learning partnerships rather than simply copied
In the light of these facts, it is paradoxical that UK interest in learning from the United States is greater than the other way round. Evidence of this learning is to be found everywhere. Back in the 1980s, the Thatcher government drew on ideas advocated by the Stanford economist, Alain Enthoven, in formulating its plans for an internal market for the NHS.8 More recently, the Blair government's reforms to the NHS have led to a renewed interest in importing policies from across the Atlantic, most obviously in the introduction of a new system for paying hospitals that draws heavily on the use of prospective payment in the United States.
Another example of learning from the United States can be found in the NHS policy on chronic disease. Partnerships have been created with organisations such as Kaiser Permanente and United Healthcare with a track record of innovation in managing chronic conditions (see bmj.com). These partnerships are focusing on the adaptation by the NHS of managed care techniques like case management, risk stratification, and predictive modelling. By comparison, the United States has shown little interest in learning from Britain, even though a steady stream of scholars over the years has studied the NHS and drawn attention to its achievements.9
UK primary care offers many lessons for the United States
Credit: SATURN STILLS/SPL
Explaining the paradox
Is there any prospect of the balance of trade in health policy ideas being reversed? If radical transformation of the financing of US health care is unlikely, several other NHS initiatives have the potential to contribute to the reform of the US healthcare system. Starfield's research has shown that countries whose healthcare systems have a strong primary care orientation tend to perform better than those that lack this orientation. In the comparative studies undertaken by Starfield and colleagues, the United Kingdom emerges as the country that has made most progress in developing provision of primary care, and this is one factor that explains why it is able to deliver universal and comprehensive health care for a much lower level of spending than the United States.11
The changes currently taking place to the general practitioners' contract, including the use of financial incentives to raise standards of care, are intended to build on the strengths of British primary care and to reward quality of service and not just the quantity of care provided.12 Interesting parallels exist with initiatives taking place in the United States designed to link payment to performance,13 suggesting that the experience of the new contract may be a potential export from the United Kingdom, even if a primary care gatekeeping system is unlikely to fit with US values. The focus of the quality payments on the treatment of common chronic conditions, which are an equal challenge for the United States and the United Kingdom, underlines the scope for learning in this area.
Another initiative with the potential to travel is the work being done in the NHS to promote quality and safety. This encompasses the preparation of national service frameworks for major clinical priorities such as coronary heart disease and diabetes and the publication of guidelines on the use of new drugs and other technologies based on analyses by the National Institute for Clinical Excellence. Other initiatives include the National Patient Safety Agency (set up to run a mandatory reporting system for logging all failures and errors and promote a culture of safety), the duty of clinical governance placed on all NHS organisations, and the establishment of the Healthcare Commission to inspect providers and report on their performance. A major investment is also being made in information technology, including the development of an electronic health record.
The activities that have been set in train in the NHS do not yet represent a completely coherent and focused programme on quality and safety, but they have provided a strong basis for further development. This was recognised in the review commissioned by the Nuffield Trust that described the programme as, "The world's most ambitious, comprehensive, systemic and intentionally funded effort to create predictable and sustainable capacity for improving the quality of a nation's health care system."14 The United Kingdom can fairly claim to be at the forefront of countries seeking to bridge the quality chasm identified by the Institute of Medicine in its landmark report of the same name.15 Its experience deserves careful study by US policy makers concerned to reduce errors and narrow the gap between best practice and actual practice shown by research published in 2003.16
Summary points
Differences in values and politics make it difficult for the United States to adapt policy ideas from the United Kingdom
The United Kingdom, by contrast, has been able to cherry pick ideas from the United States
The United States can learn from UK initiatives to pay general practitioners to raise standards of care and to promote quality and safety of health care
Both countries can learn from experience in other healthcare systems
Multilateral rather than bilateral learning
Levit K, Smith C, Cowan C, Sensenig A, Catlin A, Health Accounts Team. Health spending rebound continues in 2002. Health Aff (Milwood) 2004;23: 147-59.
Organisation for Economic Cooperation and Development. Health at a glance. Paris: OECD, 2003.
Organisation for Economic Cooperation and Development. Towards high-performing health systems. Paris: OECD, 2004.
Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, et al. Primary care and health system performance: adults' experiences in five countries . Health Aff (Millwood) 2004 Oct 28. http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.487/DC1 (accessed 15 Feb 2005).
Blendon RJ, Schoen C, DesRoches CM, Osborn R, Scoles KL, Zapert K. Inequities in health care: a five-country survey. Health Aff (Milwood) 2002;21: 182-91.
Hussey PS, Anderson GF, Osborn R, Feek C, McLaughlin V, Millar J, and Epstein, A. How does the quality of care compare in five countries? Health Aff (Millwood) 2004;23: 89-98.
World Health Organization. The World Health Report 2000. Health systems: improving performance. Geneva: WHO, 2000.
Enthoven A. Reflections on the management of the NHS. London: Nuffield Provincial Hospitals Trust, 1985.
Klein R. Risks and benefits of comparative studies: notes from another shore. Milbank Q 1991;69: 275-91.
Robinson JC. The end of managed care. JAMA 2001;285: 2622-8.
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002;60: 201-18.
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rosenthal MB, Fernandopulle R, Song HR, Landon B. Paying for quality: providers' incentives for quality improvement. Health Affairs 2004;23: 127-41.
Leatherman S, Sutherland K. The quest for quality in the NHS. London: Stationery Office, 2003.
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, De Cristofero A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.
Feachem RGA, Sekhri N, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324: 135-43.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare Programme: analysis of routine data. BMJ 2003;327: 1257-60.
Jha AK, Perlin JB, Kizer K, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;348: 2218-27.
Klein R. Learning from others: shall the last be first? J Health Polit, Policy Law 1997;22: 1267-78.(Chris Ham, professor1)
Correspondence to: c.j.ham@bham.ac.uk
Organisational differences between the US and UK healthcare systems mean that ideas have to be adapted through learning partnerships rather than simply copied
In the light of these facts, it is paradoxical that UK interest in learning from the United States is greater than the other way round. Evidence of this learning is to be found everywhere. Back in the 1980s, the Thatcher government drew on ideas advocated by the Stanford economist, Alain Enthoven, in formulating its plans for an internal market for the NHS.8 More recently, the Blair government's reforms to the NHS have led to a renewed interest in importing policies from across the Atlantic, most obviously in the introduction of a new system for paying hospitals that draws heavily on the use of prospective payment in the United States.
Another example of learning from the United States can be found in the NHS policy on chronic disease. Partnerships have been created with organisations such as Kaiser Permanente and United Healthcare with a track record of innovation in managing chronic conditions (see bmj.com). These partnerships are focusing on the adaptation by the NHS of managed care techniques like case management, risk stratification, and predictive modelling. By comparison, the United States has shown little interest in learning from Britain, even though a steady stream of scholars over the years has studied the NHS and drawn attention to its achievements.9
UK primary care offers many lessons for the United States
Credit: SATURN STILLS/SPL
Explaining the paradox
Is there any prospect of the balance of trade in health policy ideas being reversed? If radical transformation of the financing of US health care is unlikely, several other NHS initiatives have the potential to contribute to the reform of the US healthcare system. Starfield's research has shown that countries whose healthcare systems have a strong primary care orientation tend to perform better than those that lack this orientation. In the comparative studies undertaken by Starfield and colleagues, the United Kingdom emerges as the country that has made most progress in developing provision of primary care, and this is one factor that explains why it is able to deliver universal and comprehensive health care for a much lower level of spending than the United States.11
The changes currently taking place to the general practitioners' contract, including the use of financial incentives to raise standards of care, are intended to build on the strengths of British primary care and to reward quality of service and not just the quantity of care provided.12 Interesting parallels exist with initiatives taking place in the United States designed to link payment to performance,13 suggesting that the experience of the new contract may be a potential export from the United Kingdom, even if a primary care gatekeeping system is unlikely to fit with US values. The focus of the quality payments on the treatment of common chronic conditions, which are an equal challenge for the United States and the United Kingdom, underlines the scope for learning in this area.
Another initiative with the potential to travel is the work being done in the NHS to promote quality and safety. This encompasses the preparation of national service frameworks for major clinical priorities such as coronary heart disease and diabetes and the publication of guidelines on the use of new drugs and other technologies based on analyses by the National Institute for Clinical Excellence. Other initiatives include the National Patient Safety Agency (set up to run a mandatory reporting system for logging all failures and errors and promote a culture of safety), the duty of clinical governance placed on all NHS organisations, and the establishment of the Healthcare Commission to inspect providers and report on their performance. A major investment is also being made in information technology, including the development of an electronic health record.
The activities that have been set in train in the NHS do not yet represent a completely coherent and focused programme on quality and safety, but they have provided a strong basis for further development. This was recognised in the review commissioned by the Nuffield Trust that described the programme as, "The world's most ambitious, comprehensive, systemic and intentionally funded effort to create predictable and sustainable capacity for improving the quality of a nation's health care system."14 The United Kingdom can fairly claim to be at the forefront of countries seeking to bridge the quality chasm identified by the Institute of Medicine in its landmark report of the same name.15 Its experience deserves careful study by US policy makers concerned to reduce errors and narrow the gap between best practice and actual practice shown by research published in 2003.16
Summary points
Differences in values and politics make it difficult for the United States to adapt policy ideas from the United Kingdom
The United Kingdom, by contrast, has been able to cherry pick ideas from the United States
The United States can learn from UK initiatives to pay general practitioners to raise standards of care and to promote quality and safety of health care
Both countries can learn from experience in other healthcare systems
Multilateral rather than bilateral learning
Levit K, Smith C, Cowan C, Sensenig A, Catlin A, Health Accounts Team. Health spending rebound continues in 2002. Health Aff (Milwood) 2004;23: 147-59.
Organisation for Economic Cooperation and Development. Health at a glance. Paris: OECD, 2003.
Organisation for Economic Cooperation and Development. Towards high-performing health systems. Paris: OECD, 2004.
Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, et al. Primary care and health system performance: adults' experiences in five countries . Health Aff (Millwood) 2004 Oct 28. http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.487/DC1 (accessed 15 Feb 2005).
Blendon RJ, Schoen C, DesRoches CM, Osborn R, Scoles KL, Zapert K. Inequities in health care: a five-country survey. Health Aff (Milwood) 2002;21: 182-91.
Hussey PS, Anderson GF, Osborn R, Feek C, McLaughlin V, Millar J, and Epstein, A. How does the quality of care compare in five countries? Health Aff (Millwood) 2004;23: 89-98.
World Health Organization. The World Health Report 2000. Health systems: improving performance. Geneva: WHO, 2000.
Enthoven A. Reflections on the management of the NHS. London: Nuffield Provincial Hospitals Trust, 1985.
Klein R. Risks and benefits of comparative studies: notes from another shore. Milbank Q 1991;69: 275-91.
Robinson JC. The end of managed care. JAMA 2001;285: 2622-8.
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002;60: 201-18.
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rosenthal MB, Fernandopulle R, Song HR, Landon B. Paying for quality: providers' incentives for quality improvement. Health Affairs 2004;23: 127-41.
Leatherman S, Sutherland K. The quest for quality in the NHS. London: Stationery Office, 2003.
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, De Cristofero A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.
Feachem RGA, Sekhri N, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324: 135-43.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare Programme: analysis of routine data. BMJ 2003;327: 1257-60.
Jha AK, Perlin JB, Kizer K, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;348: 2218-27.
Klein R. Learning from others: shall the last be first? J Health Polit, Policy Law 1997;22: 1267-78.(Chris Ham, professor1)