By Jonathon Gabe
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Additional resources for Challenging Medicine
The Government sees it as the engine of change in the NHS and is looking to purchasers to reshape health services, and health policy more generally, by using their powers and freedoms to think more imaginatively and creatively about meeting the needs of their local communities. Purchasers constitute what many observers regard as the most significant challenge presented by the NHS reforms. The role is a new one for which new skills and ways of working are required. Few, if any, of these are yet in place.
First, there is the purchaser-provider split, and second, there is the focus on consumerism and on listening to local voices. The purchaser-provider split is seen as a means of liberating health authorities to develop services appropriate to the assessed needs of their resident populations unencumbered by the managerial responsibility for providing services directly. Conflating the purchaser and provider functions in a single organisation was regarded as resulting in a potential conflict of interest between the preferences of providers on the one hand and those of users on the other.
As a consequence, efforts in the United States to control health care costs have been only partially successful. Hospitals, too, find ways of beating the system by, for example, redirecting patients to outpatient settings where cost control is virtually non-existent (Thorpe 1992). However, both doctors and managers can and will find ways around efforts to control clinical behaviour and the micromanagement of doctors in the USA has met with only limited CHALLENGING MEDICINE 11 success. Rising costs in the health care sector, despite numerous attempts to contain them, provide proof of the failure to manage doctors effectively even in a heavily regulated health care ‘system’ (‘non-system’ might more accurately describe arrangements in the USA).