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Education And Debate

Making the NHS more like Kaiser Permanente

BMJ 2004; 328 doi: (Published 25 March 2004) Cite this as: BMJ 2004;328:763
  1. Donald Light (, professor1,
  2. Michael Dixon, chair2
  1. 1Division of Social and Behavioural Medicine, University of Medicine and Dentistry of New Jersey, USA
  2. 2NHS Alliance, Retford, Nottinghamshire, DN22 6JD
  1. Correspondence to: D Light
  • Accepted 5 March 2004

The NHS needs to break down the barriers between primary, secondary, and tertiary care

The US health maintenance organisation Kaiser Permanente has been highlighted as a successful model of integrated, cost effective care. A key policy of the NHS and other health systems is to learn from this model. However, the changes being made by the English government overlook the key features that have enabled Kaiser to develop and implement its clinical and operational programmes. We examine the importance of integrating clinical governance as well as collaborative contracting in achieving integrated, patient centred services.

Comparing the NHS and Kaiser

In a highly influential article, Feachem and colleagues compared the costs and performance of the NHS with those of Kaiser Permanente in California. They concluded that Kaiser provided much better value, largely by using only a third of the acute bed days used in the NHS.1 Several serious criticisms were levelled at the methods used, but even if they are taken into account, the Kaiser system has much lower hospital admissions and shorter lengths of stay, especially for serious illnesses.

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Ham and colleagues carried out a more methodologically sound and detailed study of the Kaiser system.2 The data show such a much higher rate of hospital admission in the NHS for bronchitis and asthma and for angina pectoris. However, the admission rates for acute myocardial infarction, heart failure, and urinary infection were so much higher in Kaiser than the NHS that specialists in the two systems could be practising different types of medicine. Nevertheless, the overall question is how do doctors in Kaiser Permanente achieve such low rates of hospital admission and lengths of stay? Ham and colleagues point to several factors in the Kaiser system:

  • Integration of funding with provision of service

  • Integration of inpatient care with outpatient care and prevention

  • Focus on …

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