The government’s pledge to raise the share of revenue from green taxes has always been problematic

One little discussed aspect of the Autumn Statement has been the ambiguous state in which it has left the commitment to environmental taxes made in the coalition agreement. Andrew Leicester and George Stoye explore the current status of this pledge, going on to argue that it is indicative of an ineffective and problematic approach to taxation

Essays in the Economics of Healthcare

How to provide and fund healthcare is becoming an increasingly important debate in many countries due to widespread demographic changes. This has led to a growing focus on inequalities in the amount and quality of care provided to different groups. This thesis contains three papers that examine the roles played by medical staff and institutional frameworks in explaining this variation. Throughout, I use the English National Health Service as a testbed to examine these roles, exploiting the institutional features of this universal public health system and its rich administrative data. In the first paper, I examine the extent to which individual doctors explain variation in patient outcomes. Studying consultants treating heart attack patients, I exploit within-hospital random assignment of patients to doctors, and the movement of staff between hospitals, to estimate the effect of individual doctors on patient survival. I show considerable variation in the quality of individual doctors, and examine potential improvements in patient survival from reassigning doctors across patients. In the second paper, I study the impacts of external regulation on the performance of doctors in English emergency departments. I extend a ‘bunching’ methodology commonly used in the tax literature to examine the impacts of the four-hour waiting time target that applies to all English hospitals. I show the regulation was successful in reducing waiting times and drastically reduced mortality. This shows that changes to the incentives of doctors can be successful in improving care quality. In the final paper, I examine the impact of reforms that allowed pre-existing private hospitals to enter public healthcare markets. I exploit historical locations of hospitals to instrument for potentially endogenous hospital entry. I show private hospital entry sizeably expanded the market, but led to little competition between new and existing hospitals, and therefore did not impact care quality

Emv2, the only endogenous ecotropic murine leukemia virus of C57BL/6J mice

With the proliferation of sequence data, great challenges are posed in the correct annotation of endogenous retroviruses, which together comprise up to ten per cent of the genomes of many organisms. It is therefore essential that all sources of information are carefully considered before drawing conclusions concerning the phylogeny, distribution and biological properties of endogenous retroviruses. We suggest that such due diligence has not been applied in the description of an endogenous ecotropic retrovirus that recently appeared in Retrovirology

Does GP Practice Size Matter? GP Practice Size and the Quality of Primary Care

This report examines trends in the organisation of general practitioner (GP) practices in England between 2004 and 2010, and the relationship between practice size and two indicators of the quality of care: Quality and Outcomes Framework (QOF) scores; emergency in patient admissions for ambulatory care sensitive (ACS) conditions. We also examine the relationship between practice size and outpatient referral behaviour. There has been a substantial change in the organisation of GP practices overtime. There has been an increase in the average number of full-time equivalent (FTE) GPs in each practice, which rose from 3.6 in 2004 to 4.2 in 2010. The share of single-handed GP practices fell by a third, from 22% to15% over this period. These changes have resulted in a shift of registered patients towards larger practices. By 2010, 76% of those who were registered with a GP practice were registered with one that had more than three FTE GPs. This compares with a figure of 69% in 2004. Using data from 2010/11, all three indicators of quality that we examined show that smaller practices are associated with poorer quality in primary care services. The precise nature and size of this relationship vary across the different measures. There is a small, positive association between QOF scores and practice size. Single-handed practices have the lowest average (mean) QOF scores, while large practices (with more than six FTE GPs) achieve the highest average scores. For ACS admissions, there is some evidence that smaller practices perform worse, on average, than larger practices and are more likely to be among the worst performing. This precise relationship differs across different conditions. Across all the conditions studied, practices with more than six FTE GPs have lower admission rates on average than smaller practices. In the case of chronic conditions, single-handed practices are most likely to be among the poorest-performing practices. Practices with three or fewer FTE GPs are less likely to refer their patients for secondary care than larger practices. Single-handed practices are also lesslikely than larger practices to refer patients for treatment by independent sector providers (ISPs). However, there is substantial variation in the quality of care within the same practice size categories. This is particularly true for single-handed practices: despite the significant prevalence of poor performance among single-handed practices, many also provide high-quality care.The relationships between GP practice size and GP behaviour are not necessarily causal. This report controls for differences in the characteristics of the practice population, the local area and the GPs themselves in order to adjust for factors that may impact on both practice size and the indicators we examine. However, a considerable number of unobservable factors remain, such as the underlying health status of the practice populations, and could explain why smaller practices tend to perform differently. This report focuses on GP practice size. There are many other characteristics of GPs that may affect patient outcomes. Further research is required in this area

The prevalence and dynamics of social care receipt

The long-term care needs of the growing older population are increasingly important issues for policymakers and society as a whole. This report uses new data from the English Longitudinal Study of Ageing - a panel survey representative of the household population aged 50 and over in England with respondents being re-interviewed biennially - to examine the prevalence of social care and the changes to the needs and care receipt of individuals across time and between different birth cohorts

People or places? Factors associated with the presence of domestic energy efficiency measures in England.

We use English household-level survey data from 1996 to 2010 to explore whether economic market failures play a significant role in explaining the presence of energy efficiency measures (loft insulation, cavity wall insulation and full double glazing) in residential properties. There appears to be a limited role for credit constraints as proxied by income, receipt of means-tested benefits or educational attainment. Private renters are significantly less likely to own efficiency measures suggesting that failures in the landlord-tenant relationship in the private-rented sector are a key barrier to uptake. More broadly, we find that it is the characteristics of the dwelling rather than those of the occupants which are the most significant explanatory factors. Our results suggest that well-targeted policies to encourage take-up of efficiency measures could focus on private landlords, long-term owner occupiers, those in older properties and those using non-metered fuels as their main heating source. However, the key target groups vary across different efficiency measures

Challenges to promoting social inclusion of the extreme poor: evidence from a large scale experiment in Colombia

We evaluate the large scale pilot of an innovative and major welfare intervention in Colombia, which combines homes visits by trained social workers to households in extreme poverty with preferential access to social programs. We use a randomized control trial and a very rich dataset collected as part of the evaluation to identify program impacts on the knowledge and take-up of social programs and the labor supply of targeted households. We find no consistent impact of the program on these outcomes, possibly because the way the pilot was implemented resulted in very light treatment in terms of home visits. Importantly, administrative data indicates that the program has been rolled out nationally in a very similar fashion, suggesting that this major national program is likely to fail in making a significant contribution to reducing extreme poverty. We suggest that the program should undergo substantial reforms, which in turn should be evaluated

New Joints: Private providers and rising demand in the English National Health Service

This paper investigates how changes in hospital choice sets affect levels of patient demand for elective hospital care. We exploit a set of reforms in England that opened up the market for publicly-funded patients to private hospitals. Impacts on demand are estimated using variation in distance to these private hospitals, within regions where supply constraints are fixed. We find that the reforms increased demand for publicly-funded procedures. For public hospitals, volumes remained unchanged but waiting times fell. Taken together, our results provide new insights into how individuals make choices about their care and the scope of competition between hospitals

Challenges to promoting social inclusion of the extreme poor: evidence from a large-scale experiment in Colombia

We evaluate the large-scale pilot program of an innovative and major welfare intervention in Colombia, which combines home visits by trained social workers to households in extreme poverty with preferential access to social programs. We use a randomized control trial and a very rich data set collected as part of the evaluation to identify program impacts on the knowledge and take-up of social programs and the labor supply of targeted households. We find no consistent impact of the program on these outcomes, possibly because the way the pilot was implemented resulted in very light treatment in terms of home visits. Importantly, administrative data indicate that the program has been rolled out nationally in a very similar fashion, suggesting that this major national program is likely to fail in making a significant contribution to reducing extreme poverty. We suggest that the program should undergo substantial reforms, which in turn should be evaluated

Negative Selection by an Endogenous Retrovirus Promotes a Higher-Avidity CD4+ T Cell Response to Retroviral Infection

Effective T cell responses can decisively influence the outcome of retroviral infection. However, what constitutes protective T cell responses or determines the ability of the host to mount such responses is incompletely understood. Here we studied the requirements for development and induction of CD4+ T cells that were essential for immunity to Friend virus (FV) infection of mice, according to their TCR avidity for an FV-derived epitope. We showed that a self peptide, encoded by an endogenous retrovirus, negatively selected a significant fraction of polyclonal FV-specific CD4+ T cells and diminished the response to FV infection. Surprisingly, however, CD4+ T cell-mediated antiviral activity was fully preserved. Detailed repertoire analysis revealed that clones with low avidity for FV-derived peptides were more cross-reactive with self peptides and were consequently preferentially deleted. Negative selection of low-avidity FV-reactive CD4+ T cells was responsible for the dominance of high-avidity clones in the response to FV infection, suggesting that protection against the primary infecting virus was mediated exclusively by high-avidity CD4+ T cells. Thus, although negative selection reduced the size and cross-reactivity of the available FV-reactive naïve CD4+ T cell repertoire, it increased the overall avidity of the repertoire that responded to infection. These findings demonstrate that self proteins expressed by replication-defective endogenous retroviruses can heavily influence the formation of the TCR repertoire reactive with exogenous retroviruses and determine the avidity of the response to retroviral infection. Given the overabundance of endogenous retroviruses in the human genome, these findings also suggest that endogenous retroviral proteins, presented by products of highly polymorphic HLA alleles, may shape the human TCR repertoire that reacts with exogenous retroviruses or other infecting pathogens, leading to interindividual heterogeneity