In 2002, a bitter argument raged in the letters pages of the BMJ. It followed the publication of a study by Feachem and colleagues comparing an American managed care organisation, Kaiser Permanente (North California), and the NHS.1 The NHS fared less well on several indicators of effectiveness and efficiency of care. Feachem and colleagues (and others) concluded that a combination of competition, better information systems, and other incentives—not just level of funding—explained Kaiser’s better performance.1 The study was quickly attacked on methodological and ideological grounds.2

Intrigued like many others, a group at the King’s Fund looked more closely at the care provided for people with long term conditions at Kaiser and four other top performing managed care organisations in the United States. We found systematic highly proactive and personalised care—nothing in theory that could not be provided in the NHS, although it frequently is not. Our conclusion was that the Department of Health should focus as much on the “how” of care (how to motivate institutions to provide good quality care)—as much as the …