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Editorials

Lessons for the NHS from Kaiser Permanente

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1241 (Published 27 November 2003) Cite this as: BMJ 2003;327:1241
  1. Jonathan Shapiro (jshapiro53{at}aol.com), senior fellow,
  2. Sarah Smith, director of performance and quality improvement (sarah.smith{at}middlesbroughpct.nhs.uk)
  1. Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
  2. Middlesbrough Primary Care Trust, Middlesbrough TS2 1HR

    Ownership and integration are the key

    Kaiser Permanente is a healthcare organisation providing managed care to 8.2 million Americans. It is widely admired for doing this in a cost effective way that is valued by both its members and its clinicians and has been closely studied over the past few years as researchers have tried to understand how it works and why it is so successful. Last year a paper by Feachem et al in the BMJ, which compared Kaiser and the NHS, provoked a sharp debate by implying that Kaiser achieved better outcomes for similar inputs.1 Now a study by Ham et al, reported in this week's BMJ, this time looking at lengths of stay in hospital (p 1257),2 has produced similar conclusions. It is time to summarise the key lessons that can be learnt from Kaiser Permanente and to consider their relevance for the NHS.

    Kaiser Permanente is essentially a closed system that offers little distinction between primary and secondary care and has well established pathways of care for many diseases. Undoubtedly the hospital based aspects of Kaiser are highly efficient. With lengths of stay well below half of those for many comparable conditions in the United Kingdom, Kaiser has put together an apparently seamless system that meets the needs of the patient from well before admission until well after discharge. Moreover, its system has fewer hospital admissions per head of population than does the NHS2 and seems to function with management costs at least as efficient as those of the NHS (B Trudell, Kaiser Permanente, personal communication).

    The two words that summarise the attributes of the Kaiser system are ownership and integration. Despite its many weaknesses, the pluralistic US healthcare system offers clinicians and the public great choice of healthcare providers. Not only is there a choice between managed care organisations and the more straightforward (if more expensive) healthcare insurers, within managed care there is also a distinction between relatively egalitarian organisations such as Kaiser and more aggressively cost conscious providers.

    People who subscribe to Kaiser Permanente do so knowing that the system aims explicitly to provide an equitable service to all its members. Many of those who visit Kaiser from the United Kingdom report that it feels highly value driven and is perhaps less materially oriented that some of its competitors. Patients who choose Kaiser Permanente are buying into this notion of egalitarianism and generally accept that their choices may be more constrained than those for subscribers to other managed care organisations. The notion of patient “buy in” (perhaps comparable to the traditional UK view of “our” NHS) permits the system to offer less inherent choice, and this must contribute to Kaiser's financial efficiency.

    As for members, so for doctors: unlike other managed care organisations, Kaiser employs its doctors, who work in large, self governed, multispecialty groups and provide their services exclusively for Kaiser. Once again, the doctors are aware of the values that underpin the organisation, and those who join do so with a commitment that distinguishes them from clinicians in other organisations. Many doctors outside Kaiser actively disparage those who sacrifice a proportion of their material ambition to satisfy a philosophical urge.

    The fact that clinicians and members have signed up to the Kaiser philosophy means that the entire service can be set up with a single set of values. Thus, the traditional distinctions between primary and secondary care, between generalists and specialists, perhaps even between doctors and nurses, may all be considered as largely obsolete. Services can be planned in a seamless way that can ignore the traditional tribal rivalries, and it is this secondary theme of integration that allows Kaiser to apply planned clinical pathways to such good effect. Unlike the NHS, structures within Kaiser create far fewer obstacles to patient care.

    How relevant is all this for the NHS? If the key determinant of success is ownership it may be that the UK government's current concern to promote choice for patients will allow both public and clinicians to opt into our own service in a way that has not been possible before. However, creating a real sense of opt in implies the possibility of opt out–a concept at odds with the NHS's principle of universality.

    The irony is that there already exists an enormous sense of ownership among both public and NHS workers. Where the system seems to have failed is in harnessing and increasing this commitment. Instead, increasing centralisation, micromanagement, and a general sense of disempowerment are causing us all to lose our sense of collective ownership. The challenge is to recreate the sense of pride and identity in the NHS: once priorities of service delivery take precedence over tribal and organisational issues, then the systems of working so effective in Kaiser Permanente that are driven by the culture of the organisation may be applied to the NHS.

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