US-style health organisations are likely in Britain

BMJ 1997; 314 doi: (Published 01 February 1997) Cite this as: BMJ 1997;314:323
  1. Jackie Cresswell
  1. London

    A report from top health service analysts predicts the development of US-style health maintenance organisations in Britain's NHS.

    The report's authors, from the Health Services Management Centre at the University of Birmingham and the Centre for Health Planning and Management at Keele University, who studied developments in primary care, state that this is the likely outcome of the NHS reforms and the primary care white paper.

    Beyond Fundholding illustrates that embryonic health maintenance organisations already exist in the form of total purchasing projects and multifunds and argues that with the emergence of these organisation there could also be an increase in competition and markets in primary care.

    Chris Ham, one of the authors, said: “Whilst a primary care market could lead to increasingly streamlined services of a higher quality, there is also a risk of fragmentation and duplication and of unacceptably high transaction costs.”

    In health maintenance organisations doctors provide what services they can in primary care for the “enrolled population” and buy in from secondary and tertiary care when necessary. There are both benefits and risks associated with these developments. The benefits include increased cost effectiveness of provision and use of care protocols and among the risks are “cream skimming” of the less costly patients and a threat to the development of secondary care specialists (see box).


    • Reduction in patient choices

    • Threat to development of secondary care specialist services

    • Threat to the traditional role of primary care as great strength of the NHS

    • Cream skimming of less costly patients

    • Fragmentation

    • Duplication

    • Higher transaction costs


    • Increased cost effectiveness of provision

    • Greater peer review and use of care protocols

    • Care management truly centred on primary care

    • Extended use of nurses in management of care

    • Primary care markets could lead to streamlined services of higher quality

    A widespread concern, according to the report, is that the traditional role of primary care as the great strength of the NHS could be compromised and eroded by overloading it with new duties and responsibilities.

    Judith Smith, at the Health Services Management Centre in Birmingham, said: “We were pleased with what we found and encouraged by the range of innovation but there are risks attached and evaluation is needed. She sees the monitoring and regulating of the future health maintenance organisations as a role for the health authorities whose commissioning role will be lost.”

    Derek Day, deputy director of the National Association of Health Authorities and Trusts, agrees with the report's predictions about the development of primary care into commissioning and provider organisations. But he disagrees that they will be like the US models, which can choose to provide only certain services. He said: “GPs would not be able to cherry pick as they have a duty to provide for all.”

    Beyond Fundholding is available from the Health Services Management Centre, Park House, Birmingham B15 2RT, price £10.00.

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