Competition and quality: rhetoric and reality.

Despite the obvious differences between the USA and UK health care systems, they share the characteristics of being motivated and managed in relation to cost and process rather than quality (the improved health status of patients). Whilst governments and insurers across the world use the rhetoric of quality, they, as epitomized by the behaviours of UK and USA decision makers, fail to define, measure and implement quality outcome policies. These behaviours are examined and some of their causes are explored briefly. Competition, as designed and used in public (e.g. UK National Health Service) and private (e.g. USA managed care) markets is shown to fail both to identify quality outcome targets and to provide evidence-based and efficient mechanisms to motivate decision makers to be orientated towards continuous quality outcome improvement in health care. A central policy challenge is, consequently, not just the measurement of quality outcomes but also their management into practice.