Published: 07/06/2002, Volume II2, No. 5808 Page 10 11
Over-priced, over-hyped and now over here? US health analysts are questioning the merits of their healthcare providers, but are they really casting covetous eyes at the NHS?
In an exclusive interview, Dr David Lawrence, senior executive of Kaiser Permanente, one of the biggest US healthcare providers, tells Ann McGauran that an American-style free-for-all is not on its way to the UK The government is flirting heavily with an American - in the shape of managed-care organisation Kaiser Permanente.
What is the potential for a longterm relationship and how far will it go?
The time is certainly ripe, with health secretary Alan Milburn wanting to bring in foreign clinical teams and overseas investment in facilities. Last week HSJ revealed that US healthcare company Johnson & Johnson has signed a strategic partnership to build, manage and potentially employ staff in privately owned diagnostic and treatment centres earmarked for NHS patients.
Is there scope for a similar role for Kaiser, whose three separate and closely co-operating organisations sell not-for-profit health plans and contract with their own not-for-profit foundation hospitals and medical groups to provide care?
Number 10's health policy adviser, Simon Stevens, made a spring trip to the company's Californian headquarters and Mr Milburn is due to meet with senior Kaiser officials this month.
President of the Boston-based Institute for Health Improvement, Don Berwick, has suggested an experiment where one strategic health authority redesigns patients' care along Kaiser programme lines.
A Department of Health spokesperson says it is interested in exploring Kaiser and other models - 'for example, those demonstrated by the US's Department for Veterans Affairs [which runs 173 hospitals] and United Health Care' (a health maintenance organisation). He points to Kaiser's 'proactive management of chronic disease in health centres, approaches to reducing language barriers and information management and technology, particularly in setting up patient records'.Kaiser also earned a glowing mention in April's final report by Derek Wanless on the future of NHS funding. Mr Wanless believes Kaiser's doctors and nurses have a wider range of skills and are able to deal with relatively complicated procedures in primary care settings. He believes a greater proportion of diagnosis and treatment could take place in primary care here.
The organisation describes itself as America's largest not-for-profit HMO, serving 8.1 million members in nine states and the district of Columbia. The bulk of its members are in California, where the organisation contracts with most metropolitan workers' unions to provide medical care.
A debate continues to rage in the UK clinical press about the relative cost-effectiveness of Kaiser's Californian business compared to the NHS.
Dr David Lawrence is chair and chief executive of the not-for-profit Kaiser Foundation Health Plans and Hospitals and retires at the end of this year. Speaking exclusively to HSJ, he says there have indeed been 'visitors from the NHS' and he is travelling to the UK this month to talk to the government.
The recent Centre for Policy Studies pamphlet Better Healthcare for All: replacing the NHS monopoly welcomes the foundation hospitals initiative and floats the idea of community mutual insurers. Would Dr Lawrence introduce not-for-profit health plans here or invest in facilities? 'I do not think anything has been ruled out, but the least likely option is for us to come to England to set up shop', he says.
'That imposes a burden on us that I do not think we are capable of carrying - [that of] functioning in a political system that is too complex and subtle for us to understand.'
He rejects the notion of being attracted to move to England as a way of taking advantage of any World Trade Organisation agenda to break down state monopolies of health services purchasing. In any case, he says, Kaiser is fully occupied back home: 'The marketplace in the US is exceedingly unstable, difficult and fully absorbing.'
He adds: 'What we are doing is beginning a rather interesting dance. There is enormous goodwill, but we are way back from where Johnson& Johnson is. We are not-for-profit.'
He doesn't believe that it will run foundation hospitals here; neither is it 'interested in running a standalone or joint venture'.What is the most likely role? 'To work side by side with NHS people to train clinical teams.We are anticipating a lot of questions about that.'
Kaiser has achieved impressive results in this area. 'For children with moderate-to-severe asthma, we get as much as a 50 per cent reduction in the requirement for emergency room visits and in the need for hospitalisation.' In diabetes care, its teams would involve a primary care internist working alongside an endocrinologist, a nurse/care co-ordinator, a dietician and possibly a podiatrist, social worker and pharmacist.
He says he is not keen on the idea that new diagnostic and treatment centre staff might receive US-style incentives such as share ownership. 'I happen to believe that medicine is an interesting and important social responsibility. When you overlay financial incentives it does contaminate your decision-making.'
Permanente Medical Groups, part of the Kaiser business, are allowed to make a profit. But Dr Lawrence says its doctors get 98 per cent of the total payment in the form of salary and they can retain a small amount based on whether or not the group meets its targets. He adds: 'As a not-forprofit, we have been careful to avoid major financial incentives'.
University College London professor of health policy and health services research Allyson Pollock, a vociferous opponent of the private finance initiative, is clear that Kaiser sees the UK as a potentially lucrative market: 'The government has now put in the structures to allow Kaiser and other HMOs to compete and contract for NHS services.'
She believes that some primary care trusts may enter into joint ventures with private health insurers and health companies to sell insurance products such as long-term care and private healthcare cover: 'The bottom has fallen out of Kaiser's market [in the US] and they are looking for new markets.'
Her view is challenged not only by Dr Lawrence, but also by longterm consultant to Kaiser Professor Alain Enthoven, the man credited with the 'invention' of the Conservatives' internal market of the early 1990s: 'I doubt Kaiser has a long-term future in the UK. It is a response to the American healthcare environment.'
But he adds: 'I think the UK could develop primary care trusts to look increasingly like HMOs.'
And it shows it would be possible to go for a US-style system in England 'if the political landscape allowed it'. l The American dream - or nightmare?
Chief executive of Manchester's Christie Hospital trust Joanna Wallace worked as a medical services planner at Kaiser Permanente in California until she took a pay cut to join the NHS five years ago.She thinks Kaiser was 'the best of the options in terms of its moral stance'of all the US health-management organisations.'Kaiser took on more than its share of Medicare and Medicaid patients and it was almost unique in not doing any pre-programme screening [to exclude expensive patients].AIDS patients always went to Kaiser. It also put a lot of effort into care of the elderly.'
But in the end, seeing the impact US healthcare systems had on people's lives 'made me realise that the NHS was worthwhile'.She saw people who could not change jobs because the new insurance did not cover a family member's medical condition.Those were the serious flaws .
She adds that Kaiser 'was not perfect'and had its share of waiting-list problems.'But the target market was the working poor.'What aspects of Kaiser would be worth copying? 'The single biggest thing is to blow away the boundary between primary and secondary care and it understands that.
What Kaiser does well is integration.'But the UK would be 'barking mad to turn to employer-based healthcare provision'.
Dr David Lawrence lectures at the Royal College of Physicians in London at 6pm on 20 June on 'Can the NHS Learn from the Kaiser Permanente Experience of Integrated Care?'. Office of Health Economics, www. ohe. org.