Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015.

Policy Points US policymakers considering proposals to expand public health care (such as "Medicare for all") as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well-funded universal health care systems are already in place. In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity. Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. CONTEXT: Expanding access to health care is once again high on the US political agenda, as is concern about those who are being "left behind." But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education-level-defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use. METHODS: Novel linkage of data from six waves (2004-2015) of the English Longitudinal Study of Ageing (ELSA) with participants' hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004-2005 to 2008-2009 and 2010-2011 to 2014-2015 to examine whether potential education-related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010. FINDINGS: For the study period, our sample of ELSA respondents in the low-education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high-education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11-0.47). Additional outpatient health care use in the high-education group was driven by follow-up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high-education group made 0.48 (95% CI, 0.21-0.74) more annual outpatient visits than those in the low-education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high-education group made 0.04 (95% CI, -0.075 to 0.001) fewer annual ED visits than the low-education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period. CONCLUSIONS: After controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high-education group using more outpatient care and less ED care than peers in the low-education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use

Public sector net worth as a fiscal target

We consider the case for and against a fiscal target for public sector net worth

The past and future of NHS waiting lists in England

NHS waiting lists are likely to be a key issue in the forthcoming general election. The current government has made cutting NHS waiting lists one of its key priorities, while one of the Labour party's five national missions is to "get the NHS back on its feet", including by cutting waiting times. In this IFS pre-election briefing, we outline what has happened to NHS waiting lists (in England, given that health is a devolved responsibility) over the last 17 years - the period for which consistent data are available - and present new scenarios of what could happen to waiting lists over the years to come. We focus on the elective waiting list - the list of people waiting for pre-planned hospital treatment and outpatient appointments. This is what most people mean when they talk about NHS waiting lists, but we also consider a range of other NHS waiting lists and waiting times. Alongside this report, we have updated our interactive online tool that allows you to produce waiting list scenarios under your own assumptions

NHS funding, resources and treatment volumes

Last month, the Chancellor set out additional funding for the National Health Service (NHS) in the Autumn Statement. This came alongside the promise of new recovery plans and targets for emergency care and primary care, a recommitment to the elective recovery plan, and a promise of a comprehensive workforce plan. These announcements come against a backdrop of continued operational pressure on all parts of the NHS, and high inflation putting pressure on NHS budgets and staff pay. In this report, the second part of the three-part series, we dig deeper into the resources available to the NHS and how they are being used, looking beyond just the waiting list. We first examine how the funding, staffing and hospital beds available to the NHS have changed since 2019. We then show how the number of patients treated by the NHS in eight different areas compares with 2019 levels. For most areas of care, the NHS is still struggling to treat more people than it was pre-pandemic, despite having - on the face of it - additional staff and funding. We therefore go on to consider a range of different factors that could explain this seeming fall in performance and output

Implications of the NHS workforce plan

The NHS workforce plan aims for a large expansion in health service staffing. We examine the potential implications for NHS funding

The fiscal implications of public service productivity

The challenging fiscal situation facing the next government means that both Labour and the Conservatives are looking for ways to improve public services without large increases in spending. Improving the productivity of public services is often proposed as a way to achieve this. This follows the big fall in measured productivity of government services - particularly in the NHS (Warner and Zaranko, 2023) - since the start of the pandemic. In the March 2024 Budget, the Chancellor, Jeremy Hunt, launched a new 'Public Sector Productivity Plan' and argued that 'the way to improve public services is not always more money or more people - we also need to run them more efficiently' (HM Treasury, 2024). Mr Hunt set out £4.2 billion of funding to improve the productivity of public services, including £3.4 billion for the NHS. In this report, we consider the current state of public service productivity and make two arguments about the potential fiscal implications of any future improvements

One year on from the backlog recovery plan: What next for NHS waiting lists?

One year ago, NHS England published its plan to tackle the backlog of elective care, which had surged following the onset of the pandemic. Since then, as widely expected, waiting lists for NHS treatment in England have continued to grow, increasing by around 1 million between February and November 2022 to just shy of 7.2 million incomplete treatment pathways. In this report, we examine whether the NHS is on track to achieve the challenging ambitions laid out in its backlog recovery plan and present a number of different scenarios for waiting lists over the next two years

How accurate are self-reported diagnoses? Comparing self-reported health events in the English Longitudinal Study of Ageing with administrative hospital records

This paper uses linked survey responses and administrative hospital records to examine the accuracy of self-reported medical diagnoses. The English Longitudinal Study of Ageing (ELSA) collects self-reported information on the incidence of heart attacks, strokes and cancer in the past two years. We compare these reports with administrative hospital records to examine whether respondents are recorded as having an inpatient admission with these diagnoses during this period. We find self-reported medical diagnoses are subject to considerable response error. More than half of respondents diagnosed in hospital with a condition in the previous two years fail to report the condition when surveyed. Furthermore, one half of those who self-report a cancer or heart attack diagnosis, and two-thirds of those who self-report a stroke diagnosis, have no corresponding hospital record. A major driver of this reporting error appears to be misunderstanding or being unaware of their diagnoses, with false negative reporting rates falling significantly for heart attacks and strokes when using only primary hospital diagnoses to define objective diagnoses. Reporting error is more common among men, older respondents and those with lower cognitive function. Estimates relying on these self-reported variables are therefore potentially subject to sizeable attenuation biases. Our findings illustrate the importance of routine linkage between survey and administrative data

The IFS Green Budget: October 2019

The IFS Green Budget 2019, in association with Citi and the Nuffield Foundation, is edited by Carl Emmerson, Christine Farquharson and Paul Johnson, and copy-edited by Judith Payne. The report looks at the issues and challenges facing Chancellor Sajid Javid as he prepares for his first Budget