Foundation Trusts: A Retrospective Review

There is limited research evidence on foundation trusts (FTs) and much of the available material is in the form of commentary or the regular reports from Monitor. Comparative research is made difficult through lack of a counter-factual and robust methods are required to overcome bias. Summary points from the literature and from some initial analysis of Monitor reports that we have undertaken for this review are given below. Future policy and research issues are highlighted in the main report.

Regional variation in the productivity of the English National Health Service

At a time when there are severe pressures on reducing public spending there is increasing emphasis on determining which parts of the country secure best value for money in the NHS. By linking together large scale and routinely collected datasets we produce and compare productivity estimates across the ten Strategic Health Authorities in England in 2007/08.

How should hospital reimbursement be refined to supportconcentration of complex care services?

The English National Health Service is promoting concentration of the treatment of patients with relatively rare and complex conditions into a limited number of specialist centres. If these patients are more costly to treat, the prospective payment system based on Healthcare Resource Groups (HRGs) may need refinement because these centres will be financially disadvantaged. To assess the funding implications of this concentration policy, we estimate the cost differentials associated with caring for patients that receive complex care and examine the extent to which complex care services are concentrated across hospitals and HRGs. We estimate random effects models using patient-level activity and cost data for all patients admitted to English hospitals during the 2013/14 financial year and construct measures of the concentration of complex services. Payments for complex care services need to be adjusted if they have large cost differentials and if provision is concentrated within a few hospitals. Payments can be adjusted either by refining HRGs or making top-up payments to HRG prices. HRG refinement is preferred to top-payments the greater the concentration of services among HRGs

Hospital Variation in Patient-Reported Outcomes at the Level of EQ-5D Dimensions : Evidence from England

•Background. The English Department of Health has introduced routine collection of patient-reported outcome data for selected surgical procedures to facilitate patient choice and increase hospital accountability. However, using aggregate health outcome scores, such as EQ-5D utilities, for performance assessment purposes causes information loss and raises statistical and normative concerns. Objectives. For hip replacement surgery, we explore a) the change in patient-reported outcomes between baseline and follow-up on 5 health dimensions (EQ-5D), b) the extent to which treatment impact varies across hospitals, and c) the extent to which hospital performance on EQ-5D dimensions is correlated with performance on the EQ-5D utility index. Methods. We combine information on pre- and postoperative EQ-5D outcomes with routine inpatient data for the financial year 2009–2010. The sample consists of 21,000 patients in 153 hospitals. We employ hierarchical ordered probit risk-adjustment models that recognize the multilevel nature of the data and the response distributions. The treatment impact is modeled as a random coefficient that varies at the hospital level. We obtain hospital-specific empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each EQ-5D dimension and the EQ-5D utility index and analyze correlations of EB estimates across these. Results. Hospital treatment is associated with improvements in all EQ-5D dimensions. Variability in treatment impact is most pronounced on the mobility and usual activities dimensions. Conversely, only pain/discomfort and anxiety/depression correlate well with performance measures based on utilities. This leads to different assessments of hospital performance across metrics. Conclusions. Our results indicate which hospitals are better than others in improving health across particular EQ-5D dimensions. We demonstrate the importance of evaluating dimensions of the EQ-5D separately for the purposes of hospital performance assessment

How much should be paid for Prescribed Specialised Services?

Overview: Current policy in the English National Health Service (NHS) promotes concentration of the specialised treatment of relatively rare and complex conditions into a limited number of specialist centres. However if a more complex patient case-mix leads to specialised treatments being systematically more costly than non-specialised treatment, then the national tariff payment system based on Healthcare Resource Groups (HRGs) may punitively penalise centres that perform this activit

Productivity of the English NHS: : 2012/13 update

Executive summary: Productivity is one of the key measures against which NHS achievements can be judged and is the focus of this report. We update our previous analyses of NHS productivity growth since 2004/05, focussing on the change in NHS productivity between 2011/12 and 2012/13, the latter financial year being the latest for which data have been made available

Analysing hospital variation in health outcome at the level of EQ-5D dimensions

The English Department of Health has introduced routine collection of patient-reported health outcome data for selected surgical procedures (hip and knee replacement, hernia repair, varicose vein surgery) to facilitate patient choice and increase provider accountability. The EQ-5D has been chosen as the preferred generic instrument and the current risk-adjustment methodology is based on the EQ-5D index score to measure variation across hospital providers. There are two potential problems with this. First, using a population value set to generate the index score may not be appropriate for purposes of provider performance assessment because it introduces an exogenous source of variation and assumes identical preferences for health dimensions among patients. Second, the multimodal distribution of the index score creates statistical problems that are not yet resolved. Analysing variation for each dimension of the EQ-5D dimensions (mobility, self care, usual activities, pain/discomfort, anxiety/depression) seems therefore more appropriate and promising. For hip replacement surgery, we explore a) the impact of treatment on each EQ-5D dimension b) the extent to which treatment impact varies across providers c) the extent to which treatment impact across EQ-5D dimensions is correlated within providers. We combine information on pre- and post-operative EQ-5D outcomes with Hospital Episode Statistics for the financial year 2009/10. The overall sample consists of 25k patients with complete pre- and post-operative responses. We employ multilevel ordered probit models that recognise the hierarchical nature of the data (measurement points nested in patients, which themselves are nested in hospital providers) and the response distributions. The treatment impact is modelled as a random coefficient that varies at hospital-level. We obtain provider-specific Empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each of the five EQ-5D dimensions and analyse correlations of the EB estimates across dimensions. Our analysis suggests that hospital treatment is indeed associated with improvements in health and that variability in treatment impact is generally more pronounced on the dimensions mobility, usual activity and pain/discomfort than on others. The pairwise correlation between the provider EB estimates is substantial, suggesting a) that certain providers are better in improving health across multiple EQ-5D dimensions than others and b) multivariate models are appropriate and should be further investigated

Productivity of the English NHS: : 2013/14 Update

The issue of NHS productivity currently holds substantial public attention, particularly given the efficiency challenge set out in the Five Year Forward View published by NHS England and other national bodies 2014. In 2015 the Department of Health appointed a Minister (Parliamentary under Secretary of State) with a specific ministerial brief for NHS productivity. This report is the latest in a regular series of NHS productivity measures produced by the Centre for Health Economics. This report updates the time-series of National Health Service (NHS) productivity to account for growth between 2012/13 and 2013/14. NHS output encompasses all activity, as valued by administrative costs, for NHS patients, and is measured by combining data from Reference Costs, Hospital Episode Statistics, Prescription Cost Analysis, and the GP Patient Survey