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Letter from America

This month, our diarist files his column from Atlanta, Georgia, where he is discovering how the US healthcare system compares with the NHS

This month, our diarist files his column from Atlanta, Georgia, where he is discovering how the US healthcare system compares with the NHS

Dr Peter Weaving is a GP in north Cumbria and locality lead for Cumbria PCT. He is currently on a three-month fact-finding sabbatical in the US to learn about its healthcare system. His first mission was to assess the pros and cons of the managed care organisation approach typified by Kaiser Permanente

Kaiser Georgia is more akin to NHS Cumbria and PBC than you might think.

Unlike its parent organisation in California, which cares for millions and runs its own hospitals there, Kaiser Georgia covers only 250,000 patients and cares for them from 15 facilities covering four to 25,000 patients – providing cradle-to-grave care for a fixed budget. It provides primary care but commissions secondary care – a familiar-sounding arrangement?

To that end, a small group of us exchanged damp and cold Cumbria for a sunny fall welcome in Atlanta, Georgia.

The case for Kaiser – for the same money, its managed healthcare system gives its patients faster, better healthcare and outcomes than the NHS is able to give.

So how does it maximise its bang for health buck? By practising evidence-based value-for-money medicine that is, in its own words, ‘safe, timely, effective, efficient, equitable and patient-centred'. They have discovered electronic records can be used proactively to ‘max-pack' the 20-minute consultation and that electronic record prompts enhance population-based care, prevention and health promotion.

How do they stop for-profit hospitals running away with investigations and expensive treatments? Invent a new doctor called a hospitalist, who sounds a lot like a GP, embed him in your local hospital where he works alongside a Kaiser case manager to ensure your patient receives speedy, appropriate treatment and leaves hospital promptly. The hospital's specialists do their bit but otherwise your generalist is in charge and taking a holistic view.

What if your patient's stay is protracted and clocking up excess hospital bed-days? An unlikely scenario, given Kaiser's age-related admission rate, which is one-third of ours.

A further development is the new ‘never event' clause. A ‘never event' is just that, something that should not happen, more correctly called a serious reportable adverse event occurring during a hospital stay. It includes such things as ‘object left in after surgery' or ‘air embolism' but is being expanded to include things such as falls and pressure sores.

The bottom line in the US is that if these events occur to your patient then the additional financial burden is borne by the hospital and not your budget. The rationale behind this punitive approach is because a survey of 1,200 US hospitals found 87% of them did not follow guidance to prevent many common hospital-acquired conditions. Would you like a copy of the survey questions for your local trust?

Overall, did Kaiser deliver good healthcare? An analysis of 230 health plans rated Kaiser top for child and maternal health. However, in a survey Kaiser was rated lowly 284th out of 400 for its ‘consumer experience'. Its patients do seem to feel the lack of choice keenly in spite of better quality care. We are coming from the other direction – out of managed care and into choice – but do our patients think so?

My thanks to my hosts at Kaiser Georgia for their justly famous Southern hospitality.

PBC diaries - letter from America

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