Intended for healthcare professionals

Rapid response to:

Papers

Getting more for their dollar: a comparison of the NHS with California's Kaiser PermanenteCommentary: Funding is not the only factorCommentary: Same price, better careCommentary: Competition made them do it

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7330.135 (Published 19 January 2002) Cite this as: BMJ 2002;324:135

Rapid Response:

Competition is good for doctors and pharmaceutical companies but not necessarily for patients

According to the World Health Report 2000 the average USA citizens
spends 3724 international dollars per year on health care while his UK
counterparts gets away with 1193 international dollars per year if
purchasing power is taken into account (1).

The higher costs in the US are almost entirely explained by higher drug
and wage costs (2). High drug and wage costs in the US are not the result
of chance but the result market of forces (competing managed care
providers compete for a finite number of doctors). In the UK, the near
monopoly positions of the NHS as an employer and consumer of drugs keeps
wage and drug bills low. It is exactly the absence of an effective market
for health care workers and health care products that benefit the ultimate
consumer of health care services.

Compared to California the UK has a lower supply of health care providers
(2). An effective market following the introduction of health maintenance
organisations into the UK should lead to higher wages in the UK than in
the US. In his commentary Enthoven (3) suggest that competition increases
quality of care without increasing cost. The opposite effect will appears
more likely if competition also results in a market for health care
providers and the fragmentation of purchaser power.

When comparing quality of care between Kaisers and the NHS Feachem et al2
choose 9 high level indicators. These cannot sufficiently describe the
performance of complex health systems. The choice of indicators is
somewhat arbitrary and a different choice would have resulted in different
outcomes. Kaisers doesn’t cover long-term mental health care and Kaisers
requires a health check prior to admitting a family to their plan. The use
of indicators assessing equity and inequality or mental health care should
give a very different quality ranking of Kaisers and the NHS.

I am not convinced by the cost or quality arguments presented.

References

1 http://www.who.int/whr/2000/index.htm

2 Feachem RGA, Neelam K Sekhri NK, White KL. Getting more for their
dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ
2002;324:135-41

3 Enthoven AC, Commentary: Competition made them do it. BMJ 2002;324:143

Competing interests: No competing interests

31 January 2002
Rudiger Pittrof
SpR GUM
London SW17 0QT