Intervening to improve outcomes for vulnerable young people : a review of the evidence

Concerns about the number of young people who fail to reach their potential at school, or get into trouble, or are not in education, employment or training (NEET), underpin the continuing commitment to end child poverty in the UK by 2020, and the Coalition Government’s pledge to increase the focus on supporting the neediest families and those with multiple problems. A strong policy commitment to improving the life chances of vulnerable young people has in recent years led to the testing of a number of initiatives. This review sought to identify: the common barriers to the effective implementation of new initiatives; elements of effective practice in the delivery of multi-agency services for vulnerable young people and their families; the costs associated with integrated service delivery; the outcomes that can be achieved; and whether fewer and more targeted initiatives might offer better value for money, particularly during a period of fiscal reform. Includes: •Introduction to the Review •Identifying and Assessing Vulnerable Young People •Multi-Agency Working: Innovations in the Delivery of Support Services •Delivering Interventions and Improving Outcomes for Young People •Assessing Value for Money in Interventions To Improve Outcomes for Young People •Looking to the Future: Defining Elements of Effective Practic

Incremental willingness to pay: a theoretical and empirical exposition

Applications of willingness to pay (WTP) have shown the difficultly to discriminate between various options. This reflects the problem of embedding in both its specific sense, of options being nested within one another, and its more-general sense, whereby respondents cannot discriminate between close substitutes or between more-disparate rivals for the same budget. Furthermore, high proportions of reversals between WTP-value and simple preference based rankings of options are often highlighted. Although an incremental WTP approach was devised to encourage more differentiated answers and a higher degree of consistency among respondents, a theoretical basis for this approach has not been elucidated, and there is little evidence to show that this approach might indeed achieve greater consistency between explicit and implicit rankings inferred from WTP values.We address both these issues. Following our theoretical exposition, standard and incremental approaches were compared with explicit ranking in a study assessing preferences for different French emergency care services. 280 persons, representative of the French adult population, were interviewed. Half received the incremental version, the other half the standard version. Results suggest that the incremental approach provides a ranking of options fully in line with explicit ranking. The standard approach was reasonably consistent with explicit ranking but proved unable to differentiate between the five most preferred providers, as predicted by theory. Our findings suggest that the incremental approach provides results which can be used in priority-setting contexts

The impact of information on patient preferences in different delivery patterns : a contingent valuation study of prescription versus OTC drugs

Our analysis assessed the impact of information on patients' preferences in prescription vs over-the-counter (OTC) delivery systems. A contingent valuation (CV) study was implemented, randomly assigning 1594 people into the receipt of limited or extended information concerning new influenza drugs. In each information arm, people answered two questions: the first asked about willingness to pay (WTP) for the new prescription drug; the second asked about WTP for the same drug sold OTC. We show that WTP is higher for the OTC scenario and that the level of information plays a significant role in the valuation of the OTC scenario, with more information increasing the WTP. In contrast, the level of information has no impact on WTP for prescription medicine. Thus, for the kind of drug (i.e. safe, not requiring medical supervision) considered here, a switch to OTC status can be expected to be all the more beneficial as the patient is provided with more information concerning the capability of the drug. Conclusions: Our results shed some light on one of the most challenging issues that health policy makers are currently faced with, namely the threat of a bird flu pandemic. Drug delivery is a critical component of pandemic influenza preparedness. Furthermore, the congruence of our results with the agency and demand theories provides an important test of the validity of using WTP based on CV methods.WTP, CV, OTC versus prescription, neuraminidase inhibitors, interval-censored regression

Health care priority setting: principles, practice and challenges

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated

Eliciting Preferences for Resource Allocation in Health Care

Willingness-to-pay (WTP) studies are increasingly being used in the evaluation of health care programmes and, although less frequently, for priority setting in health care. The usefulness of willingness-to-pay as a discriminatory tool for priority setting is considered in this paper for three different health care programmes in Ireland: cancer, cardiovascular and community care. While the resulting estimates are consistent with respondents’ rankings of the programmes, there is no statistical difference among the three programmes in terms of WTP. In considering marginal changes to existing health care programmes people consider their rankings of the programmes and the existing capacity of each programme. People are also more concerned with the gains to themselves of expanding various health care programmes than with wider issues of access or fairness.

Handling protest responses in contingent valuation surveys

OBJECTIVES: Protest responses, whereby respondents refuse to state the value they place on the health gain, are commonly encountered in contingent valuation (CV) studies, and they tend to be excluded from analyses. Such an approach will be biased if protesters differ from non-protesters on characteristics that predict their responses. The Heckman selection model has been commonly used to adjust for protesters, but its underlying assumptions may be implausible in this context. We present a multiple imputation (MI) approach to appropriately address protest responses in CV studies, and compare it with the Heckman selection model. METHODS: This study exploits data from the multinational EuroVaQ study, which surveyed respondents' willingness-to-pay (WTP) for a Quality Adjusted Life Year (QALY). Here, our simulation study assesses the relative performance of MI and Heckman selection models across different realistic settings grounded in the EuroVaQ study, including scenarios with different proportions of missing data and non-response mechanisms. We then illustrate the methods in the EuroVaQ study for estimating mean WTP for a QALY gain. RESULTS: We find that MI provides lower bias and mean squared error compared with the Heckman approach across all considered scenarios. The simulations suggest that the Heckman approach can lead to considerable underestimation or overestimation of mean WTP due to violations in the normality assumption, even after log-transforming the WTP responses. The case study illustrates that protesters are associated with a lower mean WTP for a QALY gain compared with non-protesters, but that the results differ according to method for handling protesters. CONCLUSIONS: MI is an appropriate method for addressing protest responses in CV studies