The Americanization of the British National Health Service

Prologue: Since the release of its much-discussed White Paper, Working for Patients , in 1989, the British government has been quietly going about the business of reforming its National Health Service (NHS). Three major changes proposed in that document, and implemented since then, are (1) to create an internal market to separate the financing of care from its provision; (2) to set hospitals up as self-governing trusts with budgetary autonomy and the ability to sell services to various purchasers; and (3) to establish general practitioners (GPs) as fundholders on behalf of their patients. The chief criticism of the reforms on the part of physicians and Labor Party liberals was that the NHS was being privatized and commercialized beyond recognition. Observers in the United States watched with interest as the British moved to “Americanize” their venerable NHS, in the words of David Mechanic. In this paper Mechanic, long a participant-observer of and commentator on the US. health care system, transfers his microscope to the British system, taking advantage of a year spent as visiting scholar at the London-based Kings Fund Institute to write a comparison of reform approaches, and results, in the two countries. Despite some differences in terminology, Mechanic writes, the British reforms “involved concepts that are familiar and taken for granted in the American context.” A native of New York City, Mechanic received his doctorate in sociology from Stanford University and spent many years on the faculty of the University of Wisconsin-Madison. In 1979 Mechanic moved to Rutgers University; in 1985 he established the university's Institute for Health, Health Care Policy, and Aging Research, which he directs. Mechanic is the René Dubos Professor of Behavioral Sciences at Rutgers. He is a member of the Institute of Medicine and an elected member of the National Academy of Sciences. Abstract: The core reform of the British National Health Service (NHS) was the establishment of a quasi market with a split between purchasers and providers. Health authorities and general practitioner (GP) fundholders were to be discriminating purchasers seeking more efficient and responsive services. This market orientation was embedded in a larger context of managerial, allocational, public health, and primary care changes. This paper reviews the background and dynamics of these modifications-and offers an early assessment. There is evidence that the reforms have unleashed much energy, activity, and thoughtfulness about future health care, but it remains unclear whether the gains justify the increased administrative and other transaction costs and potential threats to equal access.