Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?

The new contract for primary care in the UK offers fee-for-service payments for a wide range of activities in a quality outcomes framework, with payments designed to reflect likely workload. This study aims to explore the link between these financial incentives and the likely population health gains. The study examines a subset of eight preventive interventions covering 38 of the 81 clinical indicators in the quality framework. The maximum payment for each service was calculated and compared with the likely population health gain in terms of lives saved per 100,000 population based on evidence from McColl et al. (1998). Maximum payments for the eight interventions examined make up 57% of the sum total maximum payment for all clinical interventions in the quality outcomes framework. There appears to be no relationship between pay and health gain across these eight interventions. Two of the eight interventions (warfarin in atrial fibrillation and statins in primary prevention) receive no incentive. Payments in the new contract do not reflect likely population health gain. There is a danger that clinical activity may be skewed towards high-workload activities that are only marginally effective, to the detriment of more cost effective activities. If improving population health is the primary goal of the NHS, then fee-for-service incentives should be designed to reflect likely health gain rather than likely workload.health policy, incentive payments, primary care, quality, UK

Incentives and Gender in a Multi-task Setting: an Experimental Study with Real-Effort Tasks

This paper investigates the behavioural effects of competitive, social-value and social-image incentives on men’s and women’s allocation of effort in a multi-task environment. Specifically, using two real-effort laboratory tasks, we investigate how competitive prizes, social-value generation and public awards affect effort allocation decisions between the tasks. We find that all three types of incentives significantly focus effort allocation towards the task they are applied in, but the effect varies significantly between men and women. The highest effort distortion lies with competitive incentives, which is due to the effort allocation decision of men. Women exert similar amount of effort across the three incentive conditions, with slightly lower effort levels in the social-image incentivized tasks. Our results inform how and why genders differences may persist in competitive workplaces

A flexible multivariate conditional autoregression with application to road safety performance indicators.

There is a dearth of models for multivariate spatially correlated data recorded on a lattice. Existing models incorporate some combination of three correlation terms: (i) the correlation between the multiple variables within each site, (ii) the spatial autocorrelation for each variable across the lattice, and (iii) the correlation between each variable at one site and a different variable at a neighbouring site. These may be thought of as correlation, spatial autocorrelation and spatial cross-correlation parameters respectively. This thesis develops a exible multivariate conditional autoregression model where the spatial cross-correlation is asymmetric. A comparison of the performance of the FMCAR with existing MCARs is performed through a simulation exercise. The FMCAR compares well with the other models, in terms of model fit and shrinkage, when applied to a range of simulated data. However, the FMCAR out performs all of the existing MCAR models when applied to data with asymmetric spatial crosscorrelations. To demonstrate the model, the FMCAR model is applied to road safety performance indicators. Namely, casualty counts by mode and severity for vulnerable road users in London, taken from the STATS19 dataset for 2006. However, by exploiting correlation between multiple performance indicators within local authorities and spatial auto and cross-correlation for the variables across local authorities, the FMCAR results in considerable shrinkage of the estimates of local authority performance. Whilst this does not enable local authorities to be differentiated based upon their road safety performance it produces a considerable reduction in the uncertainty surrounding their rankings. This is consistent with previous attempts to improve performance rankings. Further, although the findings of this thesis indicate that there is only mild evidence of asymmetry in the spatial cross-correlations for road casualty counts, the thesis provides a demonstration of the applicability of this model to real world social and economic problems

Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001

International evidence suggests that there are substantial socio-economic inequalities in the delivery of specialist health services, even in the UK and other high-income countries with publicly funded health systems (Goddard and Smith 2001, Dixon et al. 2003, Van Doorslaer, Koolman and Jones 2004, Van Doorslaer et al. 2000). Studies of total hip replacement in the English NHS have yielded particularly striking examples, given that hip replacement is such a common, effective and longestablished health technology. Administrative data show that people living in deprived areas are less likely to receive hip replacement (Chaturvedi and Ben-Shlomo 1995, Dixon et al. 2004) while survey data suggest they may be more likely to need it (Milner et al. 2004). However, previous studies have not examined change in inequality over time. This paper presents evidence on the change in socio-economic inequality in small area use of elective total hip replacement in the English NHS, comparing 1991 with 2001. This was a period of important large-scale health care reform in England, involving at least two significant reforms that might potentially have influenced socio-economic inequality in health care delivery: (1) the introduction and subsequent abolition of the Conservative “internal market” 1991-7, and (2) the introduction in 1995 of a revised NHS resource allocation formula designed to reduce geographical inequalities in health care delivery. Two datasets, for 1991 and 2001, were assembled from routine NHS data sources: Hospital Episode Statistics (HES) on hospital utilisation in England and the corresponding decennial National Censuses in 1991 and 2001. Both datasets contain information on over 8,000 electoral wards in England (over 95% of the total). To improve comparability, a common geography of frozen 1991 wards was adopted. The Townsend deprivation score was employed as an indicator of socio-economic status. Inequality was analysed in two ways. First, for comparability with previous small area studies of hip replacement, by using simple range measures based on indirectly age-sex standardised utilisation ratios (SURs) by deprivation quintile groups. Second, using concentration indices of deprivationrelated inequality in use based on indirectly age-sex standardised utilisation ratios for each individual small area. Each SUR is the observed use divided by the expected use, if each age and sex group in the study population had the same rates of use as the national population.

Efficiency and Pooling in Western Cape Wine Grape Production

This paper uses a stochastic frontier and inefficiency model to test the efficiency of grape production in the Western Cape. The data covers two panels of wine grape farms (34 in Robertson and 36 in Worcester) for 2003 and 2004 and 37 table grape farms in De Doorns for 2004 only. Tests show that Cobb Douglas stochastic production frontiers, with variables to explain the inefficiencies are an appropriate representation of the five individual samples. The stochastic frontier results indicate that output can be explained by land, labour and machinery and that efficiency cab be affected by labour quality, age and education of the farmer, location, the percentage of non-bearing vines and expenditures on electricity for irrigation. These data is sufficiently good to produce reasonable results without pooling, but most applied economists would consider the possibility of improving the estimates by pooling the samples. However, pooling tests show that in this situation with small samples, when pooling is permissible it may not be helpful. More effort on determining the true distributions is needed to improve the way such samples are handled and Bayesian methods may be helpful in this respect.Crop Production/Industries, O13, Q12,