Effective commissioning

There is probably no better American observer of the NHS than Donald Light. Not only has he been a prolific author on the changes in the NHS, but he brings to bear a ready intelligence and a deep knowledge of the provision and financing of healthcare. Much of the bite of his criticism comes from his working experience with the NHS and his ability to talk to administrators, politicians, clinicians and other staff - and their willingness to talk to him.

I do not know if those who read this book will view it as the 'emperor's new clothes' and see truths in it that would otherwise have been hidden, or if they will be turned off by the audacity of an American writing a critique of their health system. I suspect there will be a combination of the two reactions in all who read it. Yet it will be hard for anyone to disagree with many of the arguments that he makes.

Light starts with a critique of the semantics that are now prevalent in health policy discussions in the UK and moves on to make the central point that there is no substitute for adequate funding. These are strongly argued passages with little subtlety, which forgo the niceties of political correctness. It is likely that they will create a serious debate within the NHS, and if this is the case Light will have achieved his desired effect. Budgeting, waiting lists, fundholding and provision of primary care are all topics that are dealt with in a succinct, critical and yet witty fashion. Light has very strong positions on everything about the NHS, not least what he sees as the disastrous reforms of the Thatcher era. But he is just as critical of the pieties of the Blair administration with regard to the NHS.

What is most surprising about the book, especially given its subtitle, is how little it has to do with anything going on in the US. For one thing, it is hard to draw any lessons at all from the US about managed care except what not to do. It is very difficult to point to real successes in this movement - in saving overall budgetary dollars, improving the effectiveness of care delivery or improving the quality of care. Congress would not be spending all its time trying to regulate managed care if it were working well. Certainly any accomplishments are local and not generalised to the healthcare system as a whole. Only a few large firms seem to have a sustained interest in improving healthcare, and this seems to be a function of particular personalities.

Thus the Xerox Corporation has made a major commitment to improving

the purchasing of health insurance for its workers, but it would be difficult to identify other purchasers of healthcare who have made a similar investment of time, personnel, and money. If anything, most human resources directors in the US seem to be heading towards abandoning any role at all in purchasing health services, instead providing a voucher and letting employees choose the plan they want. Perhaps the book would have been better served if examples from other countries were used to buttress the American illustrations Light provides.

This quibble aside, there is much to be learned from this book and I suspect that those who read it will be discussing it for a long time to come.Howard Berliner

Associate professor and chair, health services management and policy, New School for Social Research, New York.