Disease management is a term with multiple and ambiguous meanings. For some, it is purely a form of managing care. For others, it is ‘strategic planning’ by the pharmaceutical industry to market its products in a different way. In between these two ends of the semantic spectrum are a wide variety of interpretations and usage. Forms of health care management exist that embody all the principles of disease management, but which are given a different label. In this report, we explore different notions of disease management and consider their relevance to the NHS.
The topic I have been asked to address, 'Doctors, Economics and Clinical Practice Guidelines: Can they be Brought Together', is both difficult and controversial. It is also timely. With the creation of the National Institute for Clinical Excellence (NICE), the National Service Frameworks, and the clinical governance project, the UK has an opportunity to develop systematic national solutions to problems that have challenged every society - how to balance the quality and cost of health care in a way that respects both people's humanity and their pocketbooks.
From 1 April 1999 the structure of the Health Services in the United Kingdom will look radically different. In England there will be Primary Care Groups (PCGs), in Scotland Primary Care Trusts, and in Wales Local Health Groups. The pattern in Northern Ireland is still awaited. These different solutions for England, Scotland and Wales have one thing in common; they are being introduced across the board for the whole population untried and untested.
The English, Scottish and Welsh National Health Service (NHS) White Papers published by the government in December 1997 and January 1998, have changed the tone of NHS policy. Co-operation is to replace competition; there is to be a statutory requirement to provide good quality health care; and performance benchmarking is expected to succeed where market forces failed in producing efficiency gains. The consultation paper ‘Fit for the future’ published by the Department of Health and Social Services in May 1998 implies that the same changes will apply in Northern Ireland too.
Benjamin Franklin remarked in 1789 that ‘in this world nothing can be said to be certain, except death and taxes’. To these two certainties the economist would add that of the scarcity of resources, as ‘the central economic problem for society is how to reconcile the conflict between people’s virtually limitless desires for goods and services and the scarcity of resources (labour, machinery and raw materials) with which these goods and services can be produced’.
It may seem odd that someone from the most overpriced, wasteful and inequitable health care system in the industrialised world should pen a report on how to make the UK National Health Service (NHS) more cost-effective. Yet from the very deregulated nature of US markets have emerged useful lessons, as the leading buyers (that's American for 'commissioners') face up to all the ways that they did not save money during the 1980s when they thought they had. My aim is to employ familiarity with both systems in order to extract 'adaptable policy lessons' that could be used in the UK.
Caught between rising expenditure, suspected room for improved efficiency and dwindling availability of public funds, Germany's health care system is now in the forefront of public debate. In 1989 and 1993, two major legislative attempts to reform the German health sector brought home the futility of seeking to solve its problems unless the underlying structures are first reshaped. Even with the most recent health care reform, passed in July 1997, the basic characteristics of the German health care system remain largely unchanged.
This paper examines the potential for managed care techniques to develop in the UK National Health Service. It begins with a review of managed care approaches but no attempt is made here to review the wealth of material on managed care in the USA. The reasons for attempting tighter management of care and the main tools used are examined. Existing elements of the managed care approach in the NHS are then examined and the need and scope for further use of managed care tools in the NHS are explored. Finally, the potential contribution of the private sector to care management is discussed.
The 1989-1991 Conservative reforms of the National Health Service (NHS) introduced fundamental changes in the organisation of health care in the UK. At the same time they emphasised for the first time in the context of the NHS the potential benefits to patients and taxpayers of competition between care providers.
I am greatly flattered to be invited to deliver the 1998 annual lecture of the Office of Health Economics, partly on account of my distinguished predecessors, but also because this invitation provides an opportunity for a more explicitly historical perspective than is usual on these occasions. This year of the fiftieth anniversary of the National Health Service(NHS) is an especially appropriate opportunity for such an exercise.