ABSTRACT
Health care systems around the world are struggling to find the best combination of outcomes, quality of care, efficiency, and cost. The current debate in the USA about managed care offers many interesting insights into the issues. Between 1992 and 1997 the proportion of employees insured under managed care plans rose from 36 per cent to 85 per cent, and there have recently been signs of a backlash against the associated (visible) constraints on access to care (Timmins 1998). The early signs are that the temporary success in controlling costs has ended. Demands for choice of provider, direct access to specialist services and better experience of health care for patients are generating pressures for increased expenditure. This is in addition to other pressures for increased costs, such as the ageing population and increasing capacity to benefit from interventions. Governments and employers are expressing increasing concern about the effects of spending on health care programmes on economic growth and competitiveness. · The major challenges for management in the health sector are to understand these issues, distinguish between the real and imagined problems, have insight into the measurement and definitional questions and be able to identify which of the issues are tractable. It is not possible in this chapter to deal with all of the important questions, and instead the focus will be on a few areas where it may be useful to concentrate. In particular the discussion will concentrate on
quality of care, public participation in health care decision making, ageing, incentives, patient choice and control of costs.
