BMJ  2003;327 (29 November), doi:10.1136/bmj.327.7426.0-g

Editor's choice

The NHS experiment

Ownership and integration—two attributes that typify Kaiser Permanente, a healthcare organisation that provides managed care to 8.2 million Americans. Last year's BMJ paper by Richard Feachem and colleagues compared the NHS unfavourably with Kaiser and produced a strong reaction. Many of you argued this was a comparison of apples and oranges, fatally flawed; others believed that Kaiser could be a model for the NHS. A major difference between the two systems was bed usage—the NHS used three times the number of acute bed days. One GP reader wrote: "Senior NHS representatives should visit the US system described, try to work out why patients spend far less time in hospital, and then start applying the lessons learned."

Chris Ham and colleagues followed most of that advice. They examined routine data for the 11 leading causes of acute hospital admission (p 1257). Ham interviewed Kaiser's senior clinical and managerial staff, and 35 clinicians and managers from the NHS visited California to observe Kaiser's facilities and services. Can apples learn anything from oranges? Ham's team broadly confirm Feachem's findings. The differences in bed day use, they say, depend more on length of stay than admission rates. The NHS has scope to use acute hospital beds more effectively. Jonathan Shapiro and Sarah Smith believe that Kaiser is successful in large part because it is a "value driven organisation" (p 1241). Patients and doctors have signed up to the Kaiser philosophy of egalitarianism, a system that offers less choice but equitable service.

Five years ago when I researched a series of articles on the World Bank I was struck by the way people outside Britain were fascinated by the NHS. Here was a natural experiment of a health system offering universal coverage, a model that most modern policy makers bewitched by privatisation and insurance schemes would hesitate to recommend. How long before it collapsed? How to evaluate the effect of political interventions? A report from the Nuffield Trust describes the current UK government's strategy as "the most ambitious... national initiative to improve healthcare quality in the world" (p 1250). But as with other national health systems, there are insufficient good data—or analytic and evaluative capacity. Richard Smith considers the state of the NHS and concludes that we need better data to drive quality improvement (p 1239), although he doubts that "a state of quality and grace will be achieved in the NHS in another five years."

Elsewhere in this week's issue, researchers question the treatment of unilateral visual impairment detected at preschool vision screening (p 1251, p 1242); find that a smoking cessation programme delivered by cardiac nurses reduces smoking rates (p 1254); explore how health economics dictates that aspirin should be offered before statins to prevent heart disease (p 1264, p 1237); and show that the Framingham score overestimates the absolute coronary risk (p 1267). All these provide data that NHS policy makers would do well to consider.

(kabbasi{at}bmj.com)

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