Can Governments Do It Better? Merger Mania and Hospital Outcomes in the English NHS

The literature on mergers between private hospitals suggests that such mergers often produce little benefit. Despite this, the UK government has pursued an active policy of hospital merger. These mergers are initiated by a regulator, acting on behalf of the public, and justified on the grounds that merger will improve outcomes. We examine whether this promise is met. We exploit the fact that between 1997 and 2006 in England around half the short term general hospitals were involved in a merger, but that politics means that selection for a merger may be random with respect to future performance. We examine the impact of mergers on a large set of outcomes including financial performance, productivity, waiting times and clinical quality and find little evidence that mergers achieved gains other than a reduction in activity. In addition, mergers reduce the scope for competition between hospitals.

Can governments do it better? Merger mania and hospital outcomes in the English NHS

The literature on mergers between private hospitals suggests that such mergers often produce little benefit. Despite this, the UK government has pursued an active policy of hospital mergers, arguing that such consolidations will bring improvements for patients. We examine whether this promise is met. We exploit the fact that between 1997 and 2006 in England around half the short term general hospitals were involved in a merger, but that politics means that selection for a merger may be random with respect to future performance. We examine the impact of mergers on a large set of outcomes including financial performance, productivity, waiting times and clinical quality and find little evidence that mergers achieved gains other than a reduction in activity. Given that mergers reduce the scope for competition between hospitals the findings suggest that further merger activity may not be the appropriate way of dealing with poorly performing hospitals.Hospital mergers, event study, quality, political influence.

Measuring change in health care equity using small area administrative data – evidence from the English NHS 2001-8

This study developed a method for measuring change in socio-economic equity in health care utilisation using small area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1,500 and combined with other small area administrative data. Regression models of utilisation were used to examine year-on-year change in the small area association between deprivation and utilisation, allowing for population size, age-sex composition and disease prevalence including (from 2003-8) cancer, chronic kidney disease, coronary heart disease, diabetes, epilepsy, hypertension, hypothyroidism, stroke, transient ischaemic attack and (from 2006-8) atrial fibrillation, chronic obstructive pulmonary disease, obesity and heart failure. There was no substantial change in small area associations between deprivation and utilisation for outpatient visits, hip replacement, senile cataract, gastroscopy or coronary revascularisation, though overall non-emergency inpatient admissions rose slightly faster in more deprived areas than elsewhere. Associations between deprivation and disease prevalence changed little during the period, indicating that observed need did not grow faster in more deprived areas than elsewhere. We conclude that there was no substantial deterioration in socio-economic equity in health care utilisation in the English NHS from 2001 to 2008, and if anything, there may have been a slight improvement.

What explains variation in the costs of treating patients in English obstetrics specialties?

We assess patients admitted to English obstetrics departments to identify what proportion of variation in their costs is explained by patient characteristics and what proportion is due to departmental characteristics. Hospital Episode Statistics records for every patient admitted to obstetrics departments are matched to Reference Cost data by HRG reported by all English hospitals for the year 2005/6. Our sample consists of 951,277 patients in 136 departments. We estimate fixed effects models analysing patient-level costs, explore departmental characteristics that drive variation in costs at department-level and explore the sensitivity of results to the use of the full sample and sub-samples of obstetrics patients. Patient costs depend on various diagnostic characteristics over and above the HRG classification, particularly whether the patient suffered infection. After controlling for patient characteristics a substantial amount of unexplained variation in costs remains at departmental level. Higher costs are evident in departments that are not supported by a neonatology specialty and where factor prices are higher. There is evidence of lower costs in departments with high volumes of activity. We identify departments where further scrutiny of their high costs is required.

Does hospital competition harm equity? Evidence from the English National Health Service

Increasing evidence shows that hospital competition under fixed prices can improve quality and reduce cost. Concerns remain, however, that competition may undermine socio-economic equity in the utilisation of care. We test this hypothesis in the context of the pro-competition reforms of the English National Health Service progressively introduced from 2004 to 2006. We use a panel of 32,482 English small areas followed from 2003 to 2008 and a difference in differences approach. The effect of competition on equity is identified by the interaction between market structure, small area income deprivation and year. We find a negative association between market dispersion and elective admissions in deprived areas. The effect of pro-competition reform was to reduce this negative association slightly, suggesting that competition did not undermine equity.

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.

Disparities In Cancer Care And Costs At The End Of Life: Evidence From England's National Health Service

In universal health care systems such as the English National Health Service, equality of access is a core principle, and health care is free at the point of delivery. However, even within a universal system, disparities in care and costs exist along a socioeconomic gradient. Little is known about socioeconomic disparities at the end of life and how they affect health care costs. This study examines disparities in end-of-life treatment costs for cancer patients in England. Analyzing data on over 250,000 colorectal, breast, prostate, and lung cancer patients from multiple national databases, we found evidence illustrating that disparities are driven largely by the greater use of emergency inpatient care among patients of lower socioeconomic status. Even within a system with free health care, differences in the use of care create disparities in cancer costs. While further studies of these barriers is required, our research suggests that disparities may be reduced through better management of needs through the use of less expensive and more effective health care settings and treatments

Does hospital competition harm equity? Evidence from the English National Health Service

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Does hospital competition harm equity? Evidence from the English National Health Service

Increasing evidence shows that hospital competition under fixed prices can improve quality and reduce cost. Concerns remain, however, that competition may undermine socio-economic equity in the utilisation of care. We test this hypothesis in the context of the pro-competition reforms of the English National Health Service progressively introduced from 2004 to 2006. We use a panel of 32,482 English small areas followed from 2003 to 2008 and a difference in differences approach. The effect of competition on equity is identified by the interaction between market structure, small area income deprivation and year. We find a negative association between market dispersion and elective admissions in deprived areas. The effect of pro-competition reform was to reduce this negative association slightly, suggesting that competition did not undermine equity

Measuring Change in Health Care Equity Using Small Area Administrative Data : Evidence from the English NHS 2001-8

This study developed a method for measuring change in socio-economic equity in health care utilisation using small area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1,500 and combined with other small area administrative data. Regression models of utilisation were used to examine year-on-year change in the small area association between deprivation and utilisation, allowing for population size, age-sex composition and disease prevalence including (from 2003-8) cancer, chronic kidney disease, coronary heart disease, diabetes, epilepsy, hypertension, hypothyroidism, stroke, transient ischaemic attack and (from 2006-8) atrial fibrillation, chronic obstructive pulmonary disease, obesity and heart failure. There was no substantial change in small area associations between deprivation and utilisation for outpatient visits, hip replacement, senile cataract, gastroscopy or coronary revascularisation, though overall non-emergency inpatient admissions rose slightly faster in more deprived areas than elsewhere. Associations between deprivation and disease prevalence changed little during the period, indicating that observed need did not grow faster in more deprived areas than elsewhere. We conclude that there was no substantial deterioration in socio-economic equity in health care utilisation in the English NHS from 2001 to 2008, and if anything, there may have been a slight improvement