Are there ways of forcing health services to be more efficient? This was one of the aims of market oriented health care reforms. These reforms aim to contain costs and increase efficiency through more cost-effective patterns of delivery. The general trend of these reforms is towards the introduction of a number of organizational changes intended to promote a greater role for the private sector and a new culture of entrepreneurship and competition among health care providers as well as an overall management decentralisation.
The United Kingdom has, from 1991, used a system of a provider market with the aim of increasing efficiency and thus enabling health needs to be met within a lower total of expenditure. The District Health Authorities purchase hospital services from public and private hospitals under contracts placed on the basis of cost and quality. Parallel to this, groups of general practitioners covering about a third of patients have been allowed to opt to become purchasers of services. They buy, with their budgets, outpatient consultations and diagnostic tests, a limited number of elective acute hospital in-patient services and part of community services for their patients, but not emergency and obstetric services. In 1994 a scheme of GP total purchasing fundholding practices was introduced on an experimental basis. Hospitals have increasingly been allowed to become «trusts», which gives them considerable freedom from the regulations governing the National Health Service, particularly in determining the levels of pay of their staff. About 90 per cent of expenditure is made by hospitals with this status.
In London, districts are contracting with local hospitals rather than the more expensive central teaching hospitals. Some of the latter are amalgamating as a preliminary to reducing beds, although this is being done within a planned rather than a market context. There is some evidence of increased hospital activity but this is subject to major problems of definition and much may be artificial.
What is remarkable is the way the reform has been copied elsewhere, before its long term effects are known - in New Zealand and parts of Spain and Sweden.