Choice and Inequality in Public Service Access and Outcomes: The Case of Healthcare

Lead Research Organisation: Institute for Fiscal Studies
Department Name: IFS Research Team

Abstract

Over the past decade, the government in England has increased the choices available to patients about where they receive care by:






  • offering patients a formal choice about where to receive hospital treatment


  • expanding the set of hospitals patients can choose between by allowing privately owned hospitals to treat NHS patients.




This programme of research will examine how increasing patient choice has affected inequalities in the access to and use of the NHS, and the implications for subsequent health outcomes. The research will be organised around three projects:



 






  1. Responses to the choice policy by patient type or characteristics. Is there any evidence that some patient groups have benefitted more than others?


  2. Childbirth:





    • A case of repeated choice, where private providers do not deliver NHS funded care. 


    • Does choice operate differently when private providers do not enter the market?


    • Do women use their own experiences of childbirth when making decisions about subsequent pregnancies?





  3. The potential effects of future choice reforms on equity. A structural model of patient behaviour will be developed to illustrate the potential effects of potential policies that could affect patient choice.





 

 

Planned Impact

The 6 main non-academic groups will benefit from my research agenda are as follows:
1.Policy-makers within government
This group includes government and opposition politicians, and civil servants. The results of my research will demonstrate the distributional impact of past policies to increase choice, and simulate the effects of possible policy scenarios. All political parties in the UK claim that they seek to reduce health inequalities. Governments and opposition parties may therefore employ my research to help evaluate past reforms and plan future policy in both healthcare and other public services.
2.Healthcare market regulators
The healthcare market regulators in England include Monitor and the Cooperation and Competition Panel (CCP). I intend for Monitor to use the results from my research to fulfil its future role in promoting competition and safeguarding the continuity of services. For example, the degree of segmentation by patient type might affect Monitor's judgment on the degree to which providers compete, and whether the premium paid to private providers is justified by higher start up costs. The CCP could invoke my findings when deciding on mergers between healthcare providers.
3.Individuals and bodies that implement healthcare policy
This group is comprised of healthcare workers, managers and civil servants, including GPs, NHS hospital managers, the new clinical commissioning groups and NHS Commissioning Board, and the Department of Health. For example, the NHS Commissioning Board state that they will seek to "improve outcomes and guarantee no community is left behind or disadvantaged" (NHSCB, 2012). I intend that results of my research will demonstrate how the implementation of policy can affect the distributional impact of a particular reform. These groups may use this evidence to evaluate the effectiveness of previous implementation strategies or to inform the design of future implementation. For example, my findings may indicate that commissioners need to devote more resources to encouraging and supporting choice amongst disadvantaged patients.
4.Patient advocates
Patient advocates include charities, such as the Patients' Association and Age UK, and MPs. These groups will use my findings in 2 ways. First, to help lobby government on behalf of those they represent. Examples may include a charity requesting more financial and logistical support to help facilitate choice, or an MP campaigning for or against a particular healthcare provider closing, opening or merging within their constituency. Second, to provide direct support and advice to those they represent. Charities may wish to launch information campaigns or support groups; MPs might provide advice to their constituents.
5.Private healthcare providers
Any observed variation in the willingness or ability of patients to choose private providers could be affected both by the preferences of those providers, or the behaviour of NHS commissioners. Private providers may benefit from widening access and lobby commissioners to recommend their services to patients. Alternatively, new entrants might use my results to calculate an expected rate of return from opening a new centre. It is the job of Monitor to ensure that the behaviour of private providers is of benefit to patients.
6.Patients and their families
Patients will benefit directly through a greater awareness that they have the right to choose. They benefit indirectly from any improvements in the content and implementation of healthcare policy.
Whilst the primary beneficiaries in each group will be those in the UK, I believe there is potential for substantive international impact. There are a number of countries with similar healthcare systems, such as Sweden and Denmark, where it would be possible to draw direct comparisons. For other countries, there is an interest in comparing how alternative systems operate and how patients behave when faced with common features, such as new providers.
 
Description I have found that allowing private hospitals to treat patients has led to an increase in patient demand for NHS funded elective hip replacements. These additional patients that were funded by the NHS are not patients who would otherwise have paid for the treatment privately.

I have discovered that the cost of hospital care increases very rapidly after age 50. After age 50, this is entirely attributable to emergency inpatient admissions to hospital. The share of spending accounted for by those in the last year of life is approximately 10%. This is in line with a range of other developed countries.

I have found that those living in deprived areas, ethnic minorities and those with worse underlying health are less likely to choose a privately owned provider when they have an NHS funded hip replacement. Differences by local area deprivation can be explained by a combination of differences in health, proximity to providers, and GP referral patterns. Ethnic minority patients are less likely to choose a privately owned provider, even if they are in the same health, live in the same area, and are treated by the same GP as white patients.
Exploitation Route These findings could be used by the Department of Health, NHS England and commissioners in order to understand how changes in the provision of elective healths services could affect demand for health care.

The finding that emergency hospital care drives the cost of treating older people could be used to target policy efforts to contain health care costs. We also find that although substantial, spending on those in the last year of life explains only a fraction of the growth in overall spending. This highlights the need for a multi-faceted approach to contain health spending. Results from other countries in the study highlight the importance of non-hospital care costs, and in particular the role of social care in the last three years of life.

The finding that certain types of patients have benefitted less from choice policies could be used to share NHS policy in the future. This may include providing more information to GPs or more support to ethnic minority patients.
Sectors Healthcare
 
Description I have engaged with policy-makers to discuss the findings from my award. Two examples of this are as follows: 1) I contributed to a UK Statistics Agency Review of Health Statistics and attended the resulting summit. 2) I spoke with Maternity Commissioners from East London about work on Maternity unit closures that is at an early stage. This was in accordance with their beliefs, and after answering their questions and on that basis decided that it would not be beneficial to spend money contracting private consultancy firms to provide them with similar answers.
First Year Of Impact 2016
Sector Healthcare
Impact Types Policy & public services
 
Description Collaboration with Coauthors at Dartmouth and Harvard 
Organisation Dartmouth College
Country United States of America 
Sector Academic/University 
PI Contribution I have worked with Jon Skinner (Dartmouth) and Amitabh Chandra (Harvard) on a project the examines the diffusion of Percutaneous Coronary Interventions in England and the US,
Collaborator Contribution My US partners worked with the US data to produce comparable results to those I produced for the UK. I participated in two work shops in the US run by Jon Skinner, where I presented results to a multi-disciplinary audience of academics, including economists, Medical Doctors, and Sociologists. My participation in the conference was funded by Jon Skinner. I also presented by results at a Health Economics conference in Rome, where my flight was paid for by Jon Skinner.
Impact We are currently working on two papers. As a result of the collaboration, both I and Jon Skinner have joined the NBER-IFS International Network on the Value of Medical Research. Jon Skinner has received 2,500 USD for research activities. I will receive 20,000 GBP for research activities.
Start Year 2014
 
Description Medical Spending in 9 Countries around the developed world 
Organisation Aarhus University
Country Denmark, Kingdom of 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation Cornell University
Country United States of America 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation Erasmus University Rotterdam (Erasmus Universitair Medisch Centrum EUR)
Country Netherlands, Kingdom of the 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation HEC Montreal
Country Canada 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation Keio University
Department Graduate School of Science and Technology
Country Japan 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation National Bureau of Economic Research
Country United States of America 
Sector Public 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation National Graduate Institute for Policy Studies (GRIPS)
Country Japan 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation Organisation for Economic Co-operation and Development OECD
Country France, French Republic 
Sector Public 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation University College London (UCL)
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation University Duisburg-Essen
Country Germany, Federal Republic of 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation University of Copenhagen
Department Center for Protein Research
Country Denmark, Kingdom of 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Medical Spending in 9 Countries around the developed world 
Organisation University of Tilburg TiU
Department Department of Economics
Country Netherlands, Kingdom of the 
Sector Academic/University 
PI Contribution I have helped coordinate a 9 country project on patterns of medical spending across the developed world. This project resulted in a special issue of the IFS journal Fiscal Studies, which provided standardised characteristics of medical spending across the 9 countries. I guest edited the journal, co-authored a chapter for England, and co-authored an introduction that summarised the main findings. I am now co-authoring a piece that summarises and expands the work on end of life spending. This is expected to result in a publication in the Journal Health Affairs in July 2017.
Collaborator Contribution Eric French from UCL led the project. The remaining collaborators produced results for their countries.
Impact Fiscal Studies Special Issue: Medical Spending around the Developed World September-December 2016
Start Year 2015
 
Description Better Statistics Better Decisions Health and Care Summit 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact I assisted Ed Humpherson in the UK Statistics Authority review of health statistics. This providing input into the review and attending the "Better Statistics Better Decisions Health and Care Summit" in July 2016.
Year(s) Of Engagement Activity 2016
 
Description Presentation at Economics Seminar at City University 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact I presented at the City University Economics Seminar to an audience of 30 people.
Year(s) Of Engagement Activity 2016
 
Description Presentation at the Oxford University Applied Economics Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact Presentation at the Oxford University Applied Economics Seminar.
Year(s) Of Engagement Activity 2015
 
Description Presentation at the Royal Holloway Applied Economics Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact Presentation to academics at Royal Holloway, University of London
Year(s) Of Engagement Activity 2015
 
Description Presentation to the Department of Health on the Distribution of Health Spending 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presentation to the Department of Health and NHS England on a cross country project comparing patterns of individual level health spending. Following the presentation, I received several emails asking for further information.
Year(s) Of Engagement Activity 2015
 
Description Presentation to the MSc Health Policy Students at LSE 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact A presentation on patterns of individual health spending in England, with comparisons made to other countries. This presentation was a guest lecture as part of an MSc in Health Policy course.
Year(s) Of Engagement Activity 2015
 
Description Presentation: Medical spending at older ages in England: Evidence from National Health Service administrative records 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact This presentation examined the distribution of spending of in patient health care for the elderly population in England, presented by Elaine Kelly, George Stoye and Marcos Vera-Hernandez on 27 March 2015.
Year(s) Of Engagement Activity 2015
URL http://www.ifs.org.uk/publications/7781
 
Description Presentation: Public payment and private provision: The changing landscape of healthcare in the 2000s 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact "Public payment and private provision" was published in May 2013, as part of a joint work programme between IFS and Nuffield Trust, written by Elaine Kelly and George Stoye.
Year(s) Of Engagement Activity 2013
URL http://www.ifs.org.uk/publications/6793
 
Description Special Session at Royal Economic Society Conference: Discrete Choice Modelling - Applications to Helathcare 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact I organised a special session at the Royal Economic Society Congress in Brighton in March 2016. This involved presentations from 4 authors on work that involved discrete choice models applied to healthcare. The audience was approximately 50-100 people.
Year(s) Of Engagement Activity 2016
 
Description Talk at a Fiscal Policy Conference (York) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact I presented at a conference on Fiscal Policy in York. The talk focused on patterns of individual medical spending, and in particular the cost of end of life care
Year(s) Of Engagement Activity 2016
 
Description Visit to the Health and Social Care Information Centre in Leeds to present and share knowledge 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact My research team and I travelled to HSCIC in Leeds for a day of knowledge exchange that included me and a member of our team presenting our research to HSCIC analysts and HSCIC analysts and senior leadership informing us about the work of HSCIC and providing a workshop on a specific use of HSCIC data.
During the meeting I offered suggestions about how to include economists in future work to improve data access and public engagement. I was asked for a copy of my presentation on patient choice of hospital from an analyst who had attended once we had returned home.
It is hoped that this visit will spur ongoing engagement between IFS and HSCIC. We will be having a "wash up meeting" in March to discuss ways forward.
Year(s) Of Engagement Activity 2016
 
Description Workshop on Medical Spending Across the Developed World 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Co-organised a workshop on Medical Spending Across the Developed World, where academics from 8 countries presented work on patterns of individual medical spending. The aim was to understand the differences between health systems and the create a common set of statistics on patterns of individual medical spending.

In addition to academic participants, I invited policy makers from the Department of Health, NHS England and the CQC to attend. I spoke to the analysts from the Department of Health at the workshop and as a result we were invited to the Department of Health to present our results to NHS England and DH via teleconferencing.
Year(s) Of Engagement Activity 2015