Education And Debate

Interview with Alain Enthoven: is there convergence between Britain and the United States in the organisation of health services?

BMJ 1995; 310 doi: (Published 24 June 1995) Cite this as: BMJ 1995;310:1652
  1. Penny Newman, senior registrar in public healtha
  1. a North Thames Regional Health Authority, London W2 3QR
  • Accepted 4 April 1995

Is the organisation of health care in Britain becoming similar to that in the United States? Since the introduction of the internal market radical change has gripped the NHS. In the United States, despite the failure to implement coherent health care reform, a health care revolution is under way, driven by cost containment. At the centre of these changes is managed competition. Alain Enthoven, Marriner S Eccles professor of public and private management at Stanford University, has been the principal proponent of managed competition in both countries. His writings inspired the NHS reforms in 1989 and President Clinton's advisers to adopt managed competition in 1994, though ultimately he became opposed to the Clinton plan. In this interview with Penny Newman he redefines managed competition, explores the similarities and differences that have arisen between Britain and the United States, and describes recent trends in the United States, many of which are being mirrored in Britain. He illustrates a degree of convergence between the two countries. This was unthinkable 10 years ago when comparing the fee for service system in the United States with the NHS.

“Managed care-managed competition”

PN: Managed competition has become a familiar term in Britain and the United States. Please could you describe the essential elements?

AE: Lately, I've often been calling it “managed care-managed competition” to emphasise that what are meant to compete are comprehensive care organisations. Here in the United States we mean organisations that provide a comprehensive list of medical care services. They do it for a per capita amount set in advance so they don't get more money for doing more things. But they do prosper by keeping their patients healthy and satisfied. Patients have a choice so that if they aren't satisfied they can choose a different managed care organisation for the next enrolment. These organisations …

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