BMJ  2006;333:760 (7 October), doi:10.1136/bmj.333.7571.760

reviews

Book

Redefining Health Care: Creating Value-Based Competition on Results

This book "grew out of a puzzle: why is competition failing in health care?" This first sentence of the book is followed by a rationale, namely that "throughout the economy competition among private sector rivals is the most powerful force yet discovered for driving improvements in the quality and cost of products and services"—except in health care in the United States. The authors, who have studied competition in many industries, set out their hypothesis in this readable book. The book is an example of excellent value: at the time of writing the hardback, with its 506 pages of high quality paper, could be bought on www.amazon.com for only $23.10 (about £12).

After analysing what has gone wrong in the US the authors propose that "value-based competition" is needed: namely, competition that is based on the value that patients attach to good outcomes of care; and competition not between conventional hospitals and insurance companies but between integrated practice units (IPUs), services that provide end to end care for patients with, for example, cystic fibrosis or heart disease. They are dismissive of the "whole process related approach" and say that "standardised process guidelines belie the complexity of individual patient circumstances and freeze care delivery processes rather than fostering innovation."

Their argument, though powerful, has weaknesses. Firstly, the evidence base for the book is unclear and selective. For example, they cite the elimination of inpatient costs by providing integrated practice units for cholecystectomy, which has led to and resulted from "increased demand for the lower risk, highly successful laparoscopic surgery that has improved the quality of life for many patients." But they fail to cite another study that showed that, even though the operative mortality was lower, the total number of patients dying from cholecystectomy remained the same, because so many more people had the operation (New England Journal of Medicine 1994;330: 403-8[Abstract/Free Full Text]).

Undoubtedly many outcome measures could be used that are not being used. Surely we should measure the outcome of cataract operations by functional assessment rather than by using a Snellen chart? But as a manager responsible for large scale screening projects I am dependent on process measures, because outcome measures would be too slow to show problems in quality, which can sometimes be explained away by arguing that "other factors such as case mix are responsible for the poor outcome and not my competence as a manager." Furthermore, when huge gaps exist between what we know and what we do—for example, a third of patients being considered for bypass surgery or angioplasty are not even receiving aspirin and statins (Lancet 2005;306: 1925-34)—then process based guidelines still have a part to play.

The trick, as the authors point out, is to ensure that this does not stifle innovation. We have to be careful what is meant by innovation, when we consider how many innovations have killed people, and it would not be too much to argue that we should encourage innovation but only as part of research.

The authors are not trying to change the world; they focus on health care in the US. However, their arguments are stimulating, and although the evidence in support of their hypothesis is relatively limited, their central message—that the "way to transform health care is to realign competition with the value for patients"—is a challenge that every society needs to face.

We should not throw out the baby with the bath water. We need more guidelines and pathways based on best current practice, not fewer; but we could also measure the outcomes of value to patients more often and more accurately than we do now.

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UK National Screening Committee muir.gray{at}dphpc.ox.ac.uk

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Competing interest: JAMG is the author of a book to be published by Offox Press in October, How to get Better Value Healthcare.

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