No abstract

Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California. Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaiser's standardised rate, almost twice that of the Medicare California's standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a "California effect" as well as a "Kaiser effect" in hospital utilisation. Conclusion The NHS can learn from Kaiser's integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.

No abstract

Initiatives designed to improve the quality of health services and to make these services more responsive to patients have a long history. In the British National Health Service (NHS), these initiatives have recently included total quality management, business process reengineering, and quality collaboratives. Drawing on experience outside the health sector, where quality improvement methods of this kind typically originate, NHS policymakers have focused particularly on changing work processes in their quest to improve performance. In so doing they have had to confront not only the inevitable challenges of managing organizational change (Kotter 1996) but also some specific features of health care organizations that make change particularly problematic. This article analyzes and uses the NHS's experience to identify the lessons for future quality improvement initiatives. At the heart of this article is an account of one recent initiative, the national booked admissions program, which illustrates both the opportunities and the challenges in introducing and sustaining change.

Doctors who become chief executives are self-styled 'keen amateurs' and there is a need to provide more structured support to enable them to become skilled professionals. The new faculty of medical leadership and management could have an important role in this process.

No abstract

Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.

No abstract