Reforming the British National Health Service: implementation problems in London.

Often Americans, even experienced observers, seem surprised that in the late 1980s the British government decided to make fundamental changes in the British National Health Service (NHS), introducing ideas visibly adapted from the United States. More than 6 years have elapsed since Margaret Thatcher, then prime minister, introduced the Review, which led to these fundamental changes. Now that the United States is debating intensely proposed reforms to its own health care system, it seems timely to reflect on the impact that the British reforms have had, and the extent to which these were foreseen by those involved in preparing the proposals for change. In Britain, the reform's effect has been greatest in London. These reflections center on events in London as an extreme illustration of the problems encountered when government introduces radical change. The British government introduced a market system into the supply of free health care for all U.K. residents but retained overall control of the funds available to pay for its NHS. A fundamental problem it has struggled with since has been how to reconcile its own role with the essentially market-driven issues that have arisen. In the original vision, a market for supply would make clear cut the decisions about future rationalization of health services. The best hospitals would thrive, and the weaker would not. There may have been an element of wishful thinking that the difference between the most successful and the weaker hospitals would be self-evident and would reflect popularity with patients. This has clearly proved to be illusory. To that extent, the commercial analogy was flawed. Individuals, with no direct involvement in the manner or matter of pay