Education And Debate

Purchaser-provider: the international dimension

BMJ 1995; 310 doi: (Published 28 January 1995) Cite this as: BMJ 1995;310:231
  1. Alastair Mason, regional director of public healtha,
  2. Kieran Morgan, director of public healthb
  1. a South Western Regional Health Authority
  2. b Bristol and District Health Authority, Bristol BS2 8EE
  1. Correspondence to: Dr Morgan.
  • Accepted 14 November 1994

Purchaser-provider systems in health care are being implemented in several countries and are under consideration in many more. These new arrangements are described for the United Kingdom, Finland, New Zealand, and Australia, and in each case responsibility for funding, purchasing, providing, and ownership is identified. The four systems, along with managed care organisations in the United States, are also compared with regard to several important features. There is a fundamental similarity between these purchaser-provider arrangements but several key differences are well worth systematic study. This is a major challenge for academic bodies in Britain and other countries, and the opportunity to learn from each other should not be missed.

The United Kingdom is not the only country in which purchaser-provider arrangements are being introduced into taxation funded health services. Finland and Sweden have pilot projects under way, and New Zealand and Western and South Australia are implementing major changes. These arrangements undoubtedly have their origins in the commercial sector but they cannot be thought of merely as the introduction of financial transactions between health authorities and so either good or bad for that reason alone. The purchaser-provider separation brings into the open many issues about health care that have previously been obscured. With the identification of purchasers charged with commissioning health care on behalf of a population comes the question of accountability. With the advent of the general practitioner purchaser comes the ethical question of clinical decision making within a fixed budget. Despite similarities in the purchaser-provider arrangements between different countries there are important variations in approach. Study of these variations could, in time, shed light on these questions.

For about two years senior executives from agencies responsible for purchasing in Helsinki, Auckland, Perth, Adelaide, and Bristol have been comparing experiences and sharing expertise. This paper was written after a …

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