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Rapid Responses: Rapid Responses published:
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Out of the frying pan into the fire?
- Richard G Fiddian-Green (28 November 2003)
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Lessons for the NHS from Kaiser Permanente -Ownership,Integration and Medical Leadership are indeed the keys.
- Robert Morley (1 December 2003)
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NHS Temporare
- Chris L Manning (9 December 2003)
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LESSONS FOR THE NHS
- DAVID S. DAVID (16 December 2003)
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Richard G Fiddian-Green, None None
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Like Medicare the Kaiser Permanente aims to provide comprehensive care at lower cost than that provided by private health insurance. But what of the quality of care they deliver? According to the Department of Research and Evaluation, Southern California Kaiser Permanente, "implementation of quality measurement is difficult due to limited evidence on public health practices, sparse data resources, unclear accountability, and inconsistent organizational motivation" (1). It would seem to me that the Kaiser Permanente is no more than a gate -keeper doing the work that GPs do in the UK. There is most certainly no data I have seen to suggest that the outcomes Kaiser Permanente achieves for its patients is anywhere near as good as it is at The Johns Hopkins or the Mayo Clinic. If the primary objective in the NHS is to contain costs, rather than to raise the standard of care in the NHS to that currently available at The Johns Hopkins of and the Mayo Clinic, then the focus should be upon the use and abuse of drugs for the rise in expenditure on drugs is the principle causes for the rising costs of care (2). Sir William Osler, reknowned professor of medicine at The Johns Hopkins and later regius professor of medicine at Oxford, observed that "one of the first duties of the physician is to educate the masses not to take medicine". The profession has ignored his instructions and has become the primary cause for the abuse of medications. Let us focus upon what is important for our patients in terms of improving their outcome and aspire to deliver the quality of care delivered at The Johns Hopkins and the Mayo Clinic and paying for it by a more approrpiate use of medications and the avoidance of costly complications. Changing the NHS into a Kaiser Permanente would be jumping from the frying pan into the fire. 1. Derose SF, Asch SM, Fielding JE, Schuster MA. Developing quality indicators for local health departments: experience in Los Angeles County. Am J Prev Med. 2003 Nov;25(4):347-57. 2. Where the money is Is Big Pharma the next target for attack? (From The Economist print edition) Apr 26th 2003 Competing interests: None declared |
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Robert Morley, GP principal Erdington Medical Centre 103 Wood End Road Erdington Birmingham B24 8 NT
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Shapiro and Smith provide an insightful summary into possible reasons for the success of the Kaiser Permanente model when compared to the disintegrated system which is clearly failing in the National Health Service.I do however feel it important to clarify an apparent misconception regarding the employment status of Kaiser Permanente doctors which is crucial to understanding why their system works so well. The authors state that"Kaiser employs it's doctors".This is incorrect.Kaiser Permanente delivers health care through regional Permanente Medical Groups which are entirely owned,led and run by their shareholder doctors.These work in an equal and exclusive partnership with, but are totally separate from,the Kaiser Health Plans which fund the Medical Groups to provide health care for members.Shareholder doctors agree to pay themselves competitive salaries rather than take profit shares as this arrangement is consistent with the Kaiser Permanente philosophy and allows the Medical groups to attract doctors who are both of sufficiently high calibre but also of a "cultural good fit" with the organisation. The reason for the success of this model is that it allows for true medical leadership-the shareholder doctors make all decisions related to treatment and utilisation of resources and this basic underlying principle is accepted and supported by the Health Plans.As Dr.Sharon Levine,Associate Executive Director of the Permanente Medical Group in Northern California puts it,"the pen (and the mouse!) are the most expensive items of medical equipment.In other words,doctors' decisions are the main drivers of health care costs with their decisions accounting for 85% of spending and they are trusted and given incentives(of which financial bonuses play a minimal role) to make such decisions in ways which maximise both quality of care and optimise use of resources.The evidence would suggest that they succeeed. In our culture of the hegemony of the NHS manager and flattened clinical hierarchies this is all rather controversial and somewhat at odds with the authors' contention that "distinctions...between doctors and nurses may all be considered as largely obsolete". The lessons to be learned from Kaiser Permanente are those of true medical leadership as well as ownership and integration.I believe these lessons are valuable to the NHS regardless of the given method of health care funding.One can only hope that politicians take careful note. Competing interests: None declared |
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Chris L Manning, CEO Primhe (Primary care mental health and education) Teddington TW11 9HG
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Dear Sir With all the talk of Kaisers and Tsars, it is hard to see how the NHS is moving towards 'Modernisation'? I would have thought the key word is Permanente. Whilst we could argue about some of the process, or indeed the outcomes, it clearly is a values-driven outfit, with people experiencing a sense of teamwork and personal 'ownership'. Furthermore, it appears to be relatively free from the dabbling putty -fingered meddlings of short-termist narcissistic politicians..perhaps that is a further reason for its continuing success? With the most sustainable commodity in the UK now being a Delia Smith souffle, perhaps we could all work towards a model where evidence-based decisions about health, social care, education and infrastructure are exercised by balanced power-unhungry individuals, whilst the 'psychotoxics' are firewalled in a Microsoft 'Virtual' Westminster. Dr Chris Manning Competing interests: None declared |
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DAVID S. DAVID, MEDICAL DOCTOR 2222 SANTA MONICA BLVD., SUITE 302 SANTA MONICA, CA 90404
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RE: Lessons for the NHS from Kaiser Permanente, hospital bed utilization Editor, I was hoping that after the article by Feachem et al(1) in the journal in January 2002, and the overwhelming numbers of letters in the June 2002(2) issue criticizing that article and commentaries, that implied that the Kaiser health care delivery system was better and more efficient then the NHS would have ended the debate. But unfortunately the debate continues, this time with the seemingly favorable comparison of hospital bed utilization by Kaiser as compared to the NHS and U.S. Medicare(3). ---------------------------------------------------------- Having evaluated many active or former Kaiser patients and having reviewed their records, I have no doubt that Kaiser has fewer hospital admissions for any specific medical or surgical problems and shorter lengths of stay when compared to the NHS and U.S. Medicare(3). What sort of amazed me is that this comparison with regards to hospital admissions and length of stay was published despite the former debate overwhelmingly criticizing the alleged better clinical outcomes at Kaiser. ------------------------------------------------------------ One of the ways Kaiser is able to have fewer hospital admissions and fewer length of stays is simply by its economically motivated criteria for hospital admission and care. If one is willing to sacrifice quality of care for economic reasons then fewer hospital admissions and length of stay would naturally be more efficient (economically). Furthermore, by delaying and withholding hospital admission the patients will suffer greater disability, and not infrequently lose their job and with that their health insurance (Kaiser). These patients will then be eligible for social security disability and Medicare. So other Medicare providers will have to pick up the pieces with a sicker patient requiring longer hospitalization and having a much poorer outcome. So Kaiser will have delivered less costly and more economically efficient care with the illusion of better outcome than Medicare and the NHS. ------------------------------------------------------------ As to Kaiser patients being guaranteed of equitable services to all their members, this is only partially correct. The patients who are more knowledgeable can demand better health care from Kaiser and will in general get better care than those who don’t. Furthermore, in reviewing Kaiser’s charts I noticed that many of their poorly medically managed patients seem to be “non-compliant”. It’s a great way to shift the non- compliance by a medical provider to the patient. ------------------------------------------------------------ Finally, with regards to the commentary stating that the traditional distinctions between generalist and specialist even between doctors and nurses may all be considered obsolete at Kaiser is an accurate statement. The care the nurses deliver is no worse than the care their MDs deliver. This is because they all follow the same clinical pathway or guidelines and try to avoid specialist referrals. One doesn’t need an MD degree to practice cookbook medicine. However, Kaiser will readily refer to their clinics. They have a clinic for just about every ailment including “vaginitis”. They also have a sheet to advise a patient about the care of any ailment. Unfortunately, they don’t have a clinic for the delivery of good medical care. ------------------------------------------------------------ If one is healthy Kaiser has a relatively cheap insurance premium compared to some private insurers and delivers efficient and good care. But if one has a serious illness that is costly Kaiser leaves a lot to be desired. One cannot compare their care to that of the NHS or Medicare patients. Sincerely, David S. David, MD, FACP
------------------------------------------------------------ 1 Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permamente. BMJ 2002; 324: 135-43. 2 Letters to the Editor. BMJ 2002; 324: 1332-35. 3 Ham C, York N, Sutch S, Shaw R. Hospital bed utilization in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data {with commentaries by J. Shapiro and S. Smith}. BMJ 2003; 327: 1257-60. Competing interests: None declared |
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