BMJ 2002;324:135-143 ( 19 January )

Papers

Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente

Richard G A Feachem, director, ^a Neelam K Sekhri, chief executive officer, ^b Karen L White, programme development officer. ^a

^a Institute for Global Health, University of California, San Francisco and Berkeley, CA 94105, ^b Healthcare Redesign Group, Alameda, CA 94502

Correspondence to: R Feachem rfeachem{at}psg.ucsf.edu

Objective: To compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California.
Methods: The adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators.
Results: The per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS.
Conclusions: The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

What is already known on this topic Comparisons of healthcare systems in different countries have to be undertaken with great care but can be instructive The overall healthcare system in the United States is more expensive than the NHS and population health outcomes are no better The US healthcare system comprises many discrete and unique subsystems, including the health maintenance organisations What this paper adds An integrated, non-profit health maintenance organisation in California (Kaiser Permanente), with over six million members, costs about the same as the NHS but performs considerably better Kaiser's superior performance is mainly in prompt and appropriate diagnosis and treatment These findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment

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