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Logo of bmjThis ArticleThe BMJ
BMJ. 2008 January 5; 336(7634): 8–9.
PMCID: PMC2174727
Health Care and Markets

We need to be more pragmatic

Adam Paul Fitzpatrick, consultant cardiologist

I worked for two years as an attending physician at the University of California, San Francisco, and the past 12 years as a consultant in the NHS. Rampant commercialism in health care doesn’t work well,1 2 but nor does health care by slavish social dogma, as in the United Kingdom.

In my experience in the United States, university medicine was of a high calibre; knowledge and procedural skill levels were the best I have encountered, and patients were treated as individuals and routinely attended by a specialist every day, something that is unheard of in the NHS. Politics of a parliamentary or hospital kind were subservient to care.

Before I went to the US, the NHS was lean and efficient and served the sickest patients in greatest need first, with an exceptional standard at reasonable cost, albeit with long waiting times for elective care. In the 12 years since I got back, the NHS has become overrun by managers, average waiting times have been cut at very high cost by targeting hips and cataracts, and the experience of sick patients in need has deteriorated. Spending has skyrocketed, but we have little to show for it, and bigger salaries don’t seem to have made medical professionals happier. The big money has ruined a cherished institution.

Many of the 47 million Americans without insurance chose not to purchase it, although they are able to afford it, because they are young and well. US critics of their own system, such as Woolhandler and Himmelstein,2 and Michael Moore, never write about the systems that the Organisation for Economic Cooperation and Development (OECD) ranks highly—such as those of Australia, France, Belgium, and Austria—because they all involve a large dollop of realism and pragmatism and avoid the extremes of commercialism and socialism.

However, more than any of these, the future of successful health care lies in the Kaiser Permanente model. This integrates primary, secondary, and tertiary care in a single managed “wedge,” with a single budget linked to clinicians’ remuneration, with formulas for discouraging overuse. Kaiser can’t function in a socialised setting such as the NHS, and needs competition between similar “wedges” to thrive.

It is not beyond our wit to create such a system of healthy competition and incentives, care before politics, and cost control, without rampant commercialism, but I don’t see sense prevailing in my working lifetime.


Competing interests: None declared.


1. Godlee F. The market has failed. Editor’s choice. BMJ 2007;335. (1 December.) doi:10.1136/bmj.39413.597465.47
2. Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system. BMJ 2007;335:1126-9. (1 December.) [PMC free article] [PubMed]

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