Editorials

Clinical guidelines in the independent health care sector

Ever since Aneurin Bevan "stuffed the consultants' mouths with gold" the place of private medicine in the provision of health care in the United Kingdom has been much debated. With over six million lives insured--over 10% of the population--and with numbers forecast to rise,¹ the independent sector is an increasingly important provider of health care. The activities of the private sector have the potential to influence the NHS and cannot be ignored. Indeed, the private sector might act as a test bed for measures, such as clinical guidelines, that the NHS would like to see widely implemented.

Eighty per cent of private health care bought in Britain is funded by insurance. To keep premiums low, insurers must contain costs, and one perceived mechanism is evidence based medicine. Some of the larger insurers are therefore introducing clinical practice guidelines into their business. BUPA, for example, has set up clinical consensus panels to develop professionally led guidelines that will "encourage the delivery of the very best health care...both in terms of appropriateness and quality of outcome."² The clinical guidelines being developed or in use cover mainly high cost, high volume elective surgery, which constitutes the bulk of private medical insurers' business, but psychiatric and medical guidelines are also being developed.

Implicit in this activity is the belief that guidelines will eliminate inappropriate treatments, improve quality, reduce costs, free up resources, and avoid the need for rationing--a concept not usually associated with private medicine. Insurers see quality and long term cost control as closely linked. Thus the agendas of the private sector and the NHS are not so different. What is different is the approach to the implementation of guidelines. Whereas the NHS encourages the use of evidence based medicine in general and guidelines in particular to promote best practice, the independent sector will increasingly be using guidelines to authorise care before it is given or to contract with preferred providers. This guideline activity is thus a springboard for the introduction of the American concept of managed care.

Defined as "a variety of methods of financing and organising the delivery of comprehensive health care in which an attempt is made to control costs by controlling the provision of services,"³ managed care is increasingly being discussed as a possible part of future British health policy. Yet there has been little real debate on how, or indeed whether, the concept of managed care might be applied in the NHS. Its introduction and evolution in the private sector may well have lessons for the NHS.

Influencing doctors' practice towards high quality, cost effective care is critical to the success of evidence based medicine but not always easy to achieve. The contracting process has been suggested as having the potential to support the implementation of guidelines,^{4 5} though doubts have been expressed about this approach.⁶ By contracting with preferred providers to work within guidelines through managed care, private insurers could be "purchasing guidelines" to a greater extent than is currently the practice in the NHS. Will this achieve, firstly, a change in practice and, secondly, better clinical and financial outcomes?

Managed care works by modifying the practice of doctors by using clinical guidelines, by financial incentives, by restricting access to specific doctors (preferred providers), or by a combination of all three measures. If insurers are successful in using managed care to change practice nationally, in volume and across specialties, then the NHS must take note. On the other hand, if the private sector, with its strong financial levers, is unsuccessful what chance has the NHS? Just as doctors value their clinical freedom, insured patients value freedom of choice and expect a luxury product at a competitive price. They will not pay to be rationed when they can be rationed on the NHS for free. Therefore, how insurers market guidelines and managed care to both clinicians and their subscribers will be central to their success--and of great interest to the NHS.

Although a claims driven system allows insurers to evaluate use and cost, long term clinical outcome data are presently lacking. Insurers are developing increasingly sophisticated information systems which may help to overcome this problem. In addition BUPA has recently announced that it will provide some primary care services. An extension of this and other possible initiatives by some insurers, such as the establishment of health maintenance organisations, may also help to provide long term outcome data.

In the short term, cooperation with the NHS to provide data is one possibility. Some insurers are willing to cooperate with the NHS by sharing skills and information or by contributing to a clearing house for guidelines.⁷ Thus the NHS and private sector have an opportunity to cooperate by sharing information to see if guidelines can not only change practice but also realise better outcomes for less cost: in other words, to determine if all the current activity on guidelines is justified. The opportunities should not be missed.

Managed care is in its infancy in the private sector, and its evolution could go several ways. Disease management could become a reality with clinician-manager relationships becoming cooperative rather than adversarial and clinical practice guidelines resulting in high quality, cost effective care. Alternatively, managed care systems might set medical fees, decide budgets for hospitals, and set standards of practice: use of services might be controlled but clinicians and patients could be left dissatisfied. The costs of administration could outweigh any savings, and quality might not be guaranteed. As the American experience tells us, the reality is likely to be somewhere in the middle, with insurers striving to get the best from managed care while eliminating the worst.

By whatever path managed care evolves, one thing is certain: unless the independent sector, like the NHS, can deliver high quality care at an acceptable cost it will not survive in its present form. Guidelines implemented through managed care may be one answer. Whether the private sector has lessons for the NHS depends on its future development, its willingness to collaborate, and the willingness of those in the NHS to seize the opportunities. Whatever the outcome, we have an opportunity to observe managed care at work in a British setting.

Senior registrar in public health medicine Professor of epidemiology and public health Nuffield Institute for Health, University of Leeds, Leeds LS2 9PL

Gillian Fairfield, Rhys Williams 

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