Managed care and disease management in the NHS

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Abstract
What will be the role of the pharmaceutical industry? “Managed care raises fundamental issues of patient confidentiality and the ethical responsibilities of doctors which makes it an anathema for the medical profession, but it also reduces choice both for the patient and the doctor.”1 Such a comment from the chairman of council of the British Medical Association should encourage us to examine this threat carefully, yet most doctors are ignorant even about what managed care or disease management is. Managed care has been developing rapidly in the United States and is best understood by examining what is happening there. Faced with increasing health care costs, insurance companies and employers in the United States have supported groups such as health maintenance organisations, which offer care more cheaply in return for the patient surrendering some freedom. Key features include restricting the choice of doctors, providing secondary care only in selected hospitals, modifying clinical behaviour with guidelines, and emphasising primary care. Having developed such controls, organisations can then use the three essential elements of disease management: a knowledge base that quantifies the economic structure of the disease problem and describes care guidelines; a delivery system that coordinates all carers—primary, secondary, and social; and a quality improvement system to audit performance against evolving …