Smith and Mays, in an interesting and well-organized paper, examine (for England and New Zealand) how far Primary Care Organizations (PCOs) have been able to 'tip the balance' towards primary care in their host health systems. New Zealand and the UK (especially England, after devolution within the UK in the late 1990s) have often trodden similar paths in overall health system reform since the late 1980s.
This reflects not only the transference of 'modish' ideas from policy communities and the (wider) political executive in one country to the other, but also the fact that both countries have been described as having 'the fastest law in the West'. That is, both England and New Zealand have centralized polities, and are parliamentary systems with a strong executive.
Nevertheless there are differences as well as similarities in health reform-both in policy and implementation. Regarding PCOs, Smith and Mays have pointed to the different forms of, and outcomes from, primary care reform in the two countries; and to the different cultural and managerial environments below the level of 'high politics'.
My aim in this brief note is not to challenge their findings, least of all their lucid review of the literature and pertinent observations which result, but to point to some explicit and (more salient) implicit assumptions which I would like to challenge.
First, Smith and Mays suggest that the lessons to be drawn are for countries which (like England-not necessarily the UK as a whole-and New Zealand, most prominently in the 1990s) have a split between primary and secondary care (GPs and specialists.) Beyond this, however, I detect an implicit assumption that this split (whether an English-style 'purchaser/provider split', as created under the 'Thatcher reforms' of 1990 in the UK and recently deepened in England since 2001/2002, or a more traditional organizational split of historical vintage) is the best means of promoting health system objectives.