Editorial of Special issue “Industrial Organisation of the Health Sector and Public Policy”

This special issue includes a selection of papers presented at the 16th European Health Economics Workshop held in Toulouse on the 28-29 May 2015. The special issue focuses on microeconomic theoretical models in health economics, with a strong emphasis on applications of industrial organization, contract theory and public economics. The common aim is to address and answer key policy questions through rigorous and formal analyses. The papers address specific issues and interventions in relation to nutritional policies, regulation of the pharmaceutical industry, long-term care and the role of incentive schemes in stimulating healthcare provision. Both normative and positive approaches are employed

How do time trends in inhospital mortality compare? A retrospective study of England and Scotland over 17 years using administrative data

Objectives To examine the trends in inhospital mortality for England and Scotland over a 17-year period to determine whether and if so to what extent the time trends differ after controlling for differences in the patients treated. Design Analysis of retrospective administrative hospital data using descriptive aggregate statistics of trends in inhospital mortality and estimates of a logistic regression model of individual patient-level inhospital mortality accounting for patient characteristics, case-mix, and country-specific and year-specific intercepts. Setting Secondary care across all hospitals in England and Scotland from 1997 to 2013. Population Over 190 million inpatient admissions, either electively or emergency, in England or Scotland from 1997 to 2013. Data Hospital Episode Statistics for England and the Scottish Morbidity Record 01 for Scotland. Main outcome measures Separately for two admission pathways (elective and emergency), we examine aggregate time trends of the proportion of patients who die in hospital and a binary variable indicating whether an individual patient died in hospital or survived, and how that indicator is influenced by the patient’s characteristics, the year and the country (England or Scotland) in which they were admitted. Results Inhospital mortality has declined in both countries over the period studied, for both elective and emergency admissions, but has declined more in England than Scotland. The difference in trend reduction is greater for elective admissions. These differences persist after controlling for patient characteristics and case-mix. Conclusions Comparing data at country level suggests questions about the roles performed by or functioning of their healthcare systems. We found substantial differences between Scotland and England in regard to the trend reductions in inhospital mortality. Hospital resources are therefore being deployed increasingly differently over time in these two countries for reasons that have yet to be explained

First do no harm – : The impact of financial incentives on dental x-rays

This paper assesses the impact of dentist remuneration on the incidence of potentially harmful dental x-rays. We use unique panel data which provide details of 1.3 million treatment claims by Scottish NHS dentists made between 1998 and 2007. Controlling for unobserved heterogeneity of both patients and dentists we estimate a series of fixed-effects models that are informed by a theoretical model of x-ray delivery and identify the effects on dental x-raying of dentists moving from a fixed salary to fee-for-service and patients moving from co-payment to exemption. We establish that there are significant increases in x-rays when dentists receive fee for service rather than salary payments and patients are made exempt from payment. There are further increases in x-rays when a patient switches to a fee for service dentist relative to them switching to a salaried one

The socioeconomic and demographic characteristics of United Kingdom junior doctors in training across specialities.

Objective: To analyse the distribution of socioeconomic and demographic characteristics of medical trainees across different specialties in the UK. Design: Mixed logistic regression analysis of data from the National Training Survey 2013 to quantify evidence of systematic relationships between doctors’ characteristics and the specialty they are training in, controlling for the correlation between these characteristics. Setting: Data from the National Training Survey 2013, carried out by the General Medical Council. Participants: Postgraduate medical trainees. Main outcome measures: Odds ratios (calculated for both all trainees and a subsample of UK educated trainees) relating gender, age, ethnicity, place of studies, socioeconomic background and parental education to a trainee’s specialty. Results: There are systematic and substantial differences between specialties in respect of gender, ethnicity, age and socio-economic background. Being male, white British, from a better-off socioeconomic background, trained in a UK university or having parents who have tertiary education increases the chances of being in surgical specialties relative to general practice. Being male, nonwhite, mature, trained in an overseas university, from a better-off socio-economic background, or having parents who have tertiary education increases the chances of being in psychiatric specialties relative to general practice. Measured relative to general practice the gender gap is largest for surgical specialities, the ethnicity gap is greatest for acute care, emergency medicine and anaesthetics and the age-gap is large and positive for psychiatry and large and negative for acute care, emergency medicine and anesthetics. Conclusions: Differences in the characteristics of trainees will feed into the composition of the practicing profession. The persistent gender gap, the under-representation of those coming from the disadvantaged backgrounds and the inequity of educational background in some specialties will condition perceptions of the NHS and the medical profession. Our analysis contributes to a fuller understanding of the nature of these differences, which may be a matter for public concern and policy action. Remedial action if required will necessitate a better understanding of the processes of selection and self-selection into specialties that gives rise to these observed differences

Productivity of the English National Health Service : 2017/18 update

This report updates the Centre for Health Economics’ time-series of National Health Service (NHS) productivity growth for the period 2016/17 to 2017/18. NHS productivity growth is measured by comparing the growth in outputs produced by the NHS to the growth in inputs used to produce them. NHS outputs include all the activities undertaken for NHS patients wherever they are treated in England. It also accounts for changes in the quality of care provided to those patients. NHS inputs include the number of doctors, nurses and support staff providing care, the equipment and clinical supplies used, and the facilities of hospitals and other premises where care is provided

The effect of government contracting with faith-based health care providers in Malawi

We study the impact of contracting-out of maternal health care by the government of Malawi to providers from the Christian Health Association of Malawi (CHAM) in the form of Service Level Agreements (SLAs). Under a SLA, a CHAM facility provides agreed maternal and newborn services free-of-charge to patients, and is reimbursed on a fixed price per service. We merge data on health facilities in Malawi with pregnancy histories from the 2010 Malawi Demographic and Health Survey, and exploit the staggered implementation of SLAs across facilities. Using difference-in-differences, we estimate the differential effects on pregnancy- related health care utilisation to mothers residing near and far from facilities with a SLA over time. Our findings show that SLAs reduced home births and increased skilled deliveries at CHAM hospitals. We observe greater provision of prenatal care services at CHAM health centres but no overall increase in the number of prenatal care visits. We find evidence of a reduction in certain components of prenatal care

Understanding the differences in in-hospital mortality between Scotland and England

Aims: We describe differences in in-hospital mortality between Scotland and England and test whether these differences are robust to controlling for the case-mix of patients. In spite of Scotland and England having much in common in regard to their hospital systems and populations we observe trends in-hospital mortality – the percentage of elective and emergency Continuous Inpatient Spells (CIS) that ended in death – that are different: England’s in-hospital mortality rates have decreased faster than Scotland’s for both types of admissions. Data: Individual patient data from England (HES) and Scotland (SMR01) for the period 2003/04 – 2011/12. Episode data is linked into CIS. Sample: Elective and emergency admissions, including day cases and excluding maternity. Methods: Logit regression of in-hospital death on country and financial year dummies, and their interaction, controlling for age group, gender, deprivation decile, and HRG of the first episode; separately for elective and emergency admissions. Results: For elective admissions, England has a lower initial in-hospital mortality rate than Scotland, and this rate decreases in both countries but the decrease has been faster in England. For emergency admissions, England starts with a slightly higher in-hospital mortality rate and both countries in-hospital mortality rates reduce throughout the period but England’s does so faster. Conclusions: There are differences in in-hospital mortality between Scotland and England; these differences increase over time and persist when we account for patient characteristics. It is important to understand the causes and consequences of these differences and we make a number of suggestions for future research on this issue

Medical spending and hospital inpatient care in England : An analysis over time

Health care in England is predominantly provided free at the point of service through the publicly funded National Health Service (NHS). Total NHS expenditure, which has risen in real terms by an average of 3.7% per annum since the inception of the NHS in 1948, constituted 7.9% of GDP in 2012. This paper presents a summary of the trends in medical expenditure in England and then using detailed administrative data presents analysis of the growth over 15 years of expenditure and activity in hospital inpatient health care, which represents around 20-25% of all NHS expenditure. We document the coincidence of observed trends in expenditure with reported activity, morbidity and the proximity of individuals to death. We find that; (i) expenditure for both elective and emergency inpatient care broadly follows activity so expenditure is mostly driven by activity rather than unit costs; (ii) expenditure is concentrated in individuals with multiple diseases so that the prevalence and identification of complex medical conditions are important drivers of expenditure and (iii) health care activity rises substantially for individuals in the period before death so that expenditure is driven substantially by mortality in the population. Taken together these findings indicate that this element of health care expenditure in England has been substantially driven by the underlying morbidity and age of the population in conjunction with improving health care technolog