Published: 22/04/2002, Volume II4, No. 5902 Page 21

Prepaid group practice never entered mainstream US healthcare.But this system of integrated care delivery holds lessons for the UK, finds Chris Ham

Toward a 21st Century Health System The contributions and promise of prepaid group practice Eds Alain C Enthoven and Laura A Tollen Published by Jossey-Bass. ISBN 0787973092. $30

Toward a 21st Century Health System is the story of why prepaid group practice (PGP) failed to enter the US mainstream.

The story is traced from the establishment of the Mayo Clinic in the 19th century through the creation of Kaiser Permanente in the 1930s to the encouragement of health maintenance organisations in the 1980s.

Unlike most forms of medical care in the US, PGP typically brings together primary care physicians and specialists in integrated delivery systems. The increasing complexity of medicine provides PGPs with the opportunity to demonstrate superior performance, as well as the quality described by the Institute of Medicine in its landmark 2001 report, Crossing the Quality Chasm.

In their contribution, Shortell and Schmittdiel of Berkley University's school of public health identify many examples of how PGPs meet the quality criteria identified by the institute.Yet like other contributors to the book, they note that evidence comparing the performance of PGPs with other forms of provision is inconclusive. If PGPs are able to demonstrate better results in some areas, like prevention and lower hospital use, they do not do as well in others, including patient satisfaction.

One difficulty for the authors is the lack of comprehensive evidence on PGPs. This is compounded by the failure of researchers to examine the performance of integrated systems like Kaiser separately from that of other types of HMO. Despite these difficulties, there is some evidence that PGPs do achieve better results than other providers in the management of people with chronic conditions.

There is also evidence of differences in the use of the medical workforce. This is demonstrated by Jonathan Weiner of John Hopkins University, who shows that PGPs use fewer doctors than other providers.Weiner also demonstrates that PGPs use nurses and other non-medical providers extensively in both primary care and other settings.

Following the flight from managed care into consumer choice health plans, the future for PGPs is uncertain. This is underlined in the concluding chapter by Alain C Enthoven, who notes that organisations like Kaiser Permanente will face real difficulty in maintaining their commitment to prevention and chronic-disease management in the face of market pressures.

The outcome may be that PGPs will become more like other providers, rather than vice versa, especially if competition is based on cost rather than quality.As Jamie Robinson notes, the prospect then is that US medical care will end up going back to the future, and 'the structure of physician practice in 2020 will approximate that of the profession a century earlier'.

The real importance of this book may be the lessons it holds for the NHS and other systems with greater receptivity to the principles of PGP. As the managed-care backlash demonstrated, in limiting choice and emphasising continuity of care PGP is distinctly un-American. On the other hand, in encouraging the integration of care within a system of capitation funding it has attracted interest from UK policy-makers, managers and clinicians.

From this perspective, the contribution by Francis Crosson and colleagues on the role of medical leadership in PGP should be required reading. The challenge they describe - how to get eagles to fly in formation - will be familiar to anyone who has tried to engage clinicians in management.

A brief review cannot do justice to the range of issues explored in this volume. The bringing together of leadingedge analysts like Don Berwick, Hal Luft and David Eddy and the coverage of major themes such as technology assessment, use of IT, and pharmacy benefits can only give a flavour of the contents. For anyone with an interest in those aspects of healthcare in the US that hold lessons for the NHS, Toward a 21st Century Health System repays careful study. l Chris Ham is director of the Department of Healthstrategy unit.