No stopping no fault.
Authors: R. Smith
Journal: BMJ (1988)

based on general practitioners could be developed in Britain: general practitioners would be given full budgets according to the number of people they cared for.But quite apart from the administrative and managerial nightmares, there is no reason to suppose that such an organisation would provide a more efficient or effective service than the existing NHS.The currently fashionable idea of the "internal market" borrows from the concept of the health maintenance organisation; Professor Alain Enthoven, who has recently popularised the idea of the internal market, is a major advocate of health maintenance organisations in the United States.With the internal market the health district would act as the health maintenance organisation, buying and selling care on behalf of its population according to criteria of efficiency as well as equity and geographical location.It could be argued, however, that the district health authority in Britain is already a health maintenance organisation of a sort-receiving its yearly money for its enrolled population from the govern- ment.The important question is thus whether anything would be gained by their trading through an internal market.The Institute of Economic Affairs Health Unit has proposed British style health maintenance organisations, and other proposals for radical reform or replacement of the NHS have also drawn heavily on the concept of the health maintenance organisations.For example, the Adam Smith Institute has proposed that "health management units" should enrol patients and contract with a largely privatised hospital system to provide care for patients, as many health maintenance organisations do in the United States.These schemes are, however, based on ideological acts of faith and offer little to the task of improving equity and allocating resources more effectively in the British NHS.It should not be forgotten that the friendly societies and working men's guilds that existed before the NHS used capitation fees from working people to contract for health care.Thus to adopt a system of health maintenance organisations could be to return to a voluntary system of care in which coverage was uneven and planning virtually non-existent.Back in the United States the Rand Corporation has conducted a large 10 year study of health maintenance organisations with a grant of over $100m from the federal government.' 2 The study compared health maintenance organisations with other ways of providing and financing health care.The study has concluded that the costs of sharing can cut the usage of healthcare services and that prepaid schemes are cheaper than fee for service schemes but that the availability of care will not match need geographically.This means that the advantages of health maintenance organisations are irrelevant to Britain, where costs are already low, but the disadvantages are very relevant because the provision of care is already unequal.The Rand team's research has suggested that health maintenance organisations may under- provide just as fee for service schemes overprovide.3The poor and chronically sick would inevitably be the main losers because of underprovision, and arguments that this would not happen if health maintenance organisations were introduced within the NHS are unconvincing.