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At the heart of general practice since 1960

Criminally insane

NHS managers spend half their lives talking about Kaiser Premanente, but how does it actually work, and is it a health care system that can realistically be compared

with the NHS? Dr Peter Stott explains

You can't mix with NHS managers very long without hearing someone mention 'Kaiser Permanente'.

Kaiser is a US health maintenance organisation much admired by politicians. David Colin-Thome, our primary care czar, declares it gave him 'his moment of enlightenment'. It is hailed as offering a new model for the NHS and is one of the most studied health care systems in the world. So what is so special and what can we learn? As GPs, should we love it or should we loathe it?

Kaiser is older than the NHS. It was founded as a doctor-led, insurance-based family health service for Kaiser shipyard and steel workers in 1942. It was immediately successful and opened to the general public in 1945. Now it is the largest not-for-profit health care organisation in the US serving 8.1 million members in 10 states and with an annual revenue of $22.5 billion. It is led by the 11,000 doctors who work in it.

It has 134,000 employees, 30 hospitals and 431 clinics. It focuses on an integrated and proactive approach to chronic disease, and its philosophy has always been to break down the barriers between primary and secondary care so that patients can receive more specialised care, closer to home.

The year of notoriety

Kaiser achieved UK notoriety in 2002 when the BMJ published a paper entitled 'Getting more for their dollar'. This was a comparison of Kaiser in California with the NHS.

This paper suggested that while the costs of Kaiser and the NHS were broadly similar, Kaiser patients were getting better value for money with better and more comprehensive primary care services, more rapid access to specialists and more rapid hospital admission. Most challenging of all was the finding that even after adjustment for age, the rates of Kaiser hospital admissions were one-third of those in the NHS.

This was the holy grail as far as our health service planners were concerned and cost-efficiency teams were rapidly dispatched across the Atlantic to see how Kaiser strategies could be applied within the NHS. What they found has been a subject of debate ever since.

Differences from the NHS

First, they found the Kaiser financial model was not the same as the NHS. All health maintenance organisations are insurance-based and therefore selective in whom they care for. Only 76 per cent of Californians are insured; Kaiser caters only for educated people in employment or who are affluent enough to join.

It does not cover the 24 per cent who are sickest, most disabled, most unemployed and most expensive.

In comparison, the NHS is universal in its coverage ­ including even the uninsurable, who live in poor circumstances and who account for many of our admissions. So we should not take too much notice of the economic comparisons.

Plus points

There are many facets of Kaiser that merit attention. First is its phenomenal popularity with patients and doctors. This is put down to strong clinical leadership from hands-on doctors, with local medical directors in charge of specialist multidisciplinary teams. In Kaiser, clinician decisions are supported by managerial action. There is no top-down feel as so often is the case in the NHS. Kaiser is actually not 'not-for-profit' at all. Like UK general practice, the profits form the salaries of the doctors. So Kaiser clinicians are highly motivated to work smarter, to keep patients out of hospital and to minimise overall costs.

Second is Kaiser's focus on preventive care and the recognition that the patient is at the centre of the service. A major part of the organisation is devoted to regular nurse-led reviews and the creation of health care plans for individual family members. This is provided by highly-trained staff who screen and advise patients according to standard operating procedures.

John Reid recently announced that he wanted GPs to offer people individual health care plans. He got that idea from Kaiser.

Third is the focus on proactive methods to keep patients out of hospital. A lot of work has gone into identifying those patients who are most likely to need readmission. This is not rocket science. The major risk factor is having been admitted once before; and the next is having a long-term medical condition. Each of the at-risk patients gets an individual nurse who keeps in contact, ensures compliance and monitors response to therapy, and who identifies early signs of deterioration.

This keeps people out of hospital. Remember community matrons? They got that idea from Kaiser too.

Lastly, when patients do need hospital admission, their stay is likely to be short because Kaiser is great at providing support for people in the community.

Patients' average length of hospital stay after stroke or hip fracture, for example, is five times shorter than in the NHS. Patients who are discharged do not go directly home but are transferred to a 'skilled nursing facility' and managed by a multidisciplinary team. Remember intermediate care? That's another idea the NHS got from Kaiser.

What do the doctors do?

In case you are wondering what the doctors do all day, Kaiser has a cunning plan. In Kaiser, patient care falls into three levels:

·Level 1 Patient self-care which follows the individual health care plans created in consultation with a nurse. Some 70-80 per cent of care is provided in this way: eg diet, exercise, smoking cessation.

·Level 2 Disease management: management of single problems like diabetes, asthma or hypertension according to rigid standard operating procedures. This process is overseen by doctors even though the hands-on care is provided by a nurse.

·Level 3 Complex case management: cases from level 2 felt to be more appropriately managed by a doctor, plus patients who have more than one medical condition with complex risk.

Doctors supervise nurse activity in level 2 and provide hands-on care for patients in level 3. They also supervise the work of the community teams. In this way, the doctors' special skills are cascaded most efficiently.

Kaiser has lots of figures to back up its claims and, despite the problems in translation, many of its principles are directly transferable to the NHS. No wonder everyone finds it so interesting and the Government has commissioned eight PCT projects to pilot the possibilities.

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