Consumer choice, competition and privatisation in European health and long-term care systems: subjective well-being effects and equity implications

Consumer choice has become a key reform trend in the provision of public services in Western European welfare states. Research on the welfare effects of choice reforms – including greater provider choice for the individual and competition between providers – has largely focused on economic evaluations of the extrinsic (outcome) effects of choice, thereby leaving its intrinsic, or procedural, value unexplored. The overarching objective of this thesis is to investigate the welfare effects of choice in the provision of health and long-term care (LTC) and their implications for equity. The thesis utilises the subjective well-being approach – incorporating both procedural and outcome utility from choice – to measure welfare effects based on quantitative analysis of survey data. Welfare effects and equity implications are examined in relation to: competition in health care in the English National Health System (NHS); choice of care package in the German long-term care system; and individual preferences and views of choice as a priority in the provision of health care in three NHS countries. The thesis argues that both service characteristics – extent of competition, information availability, technical complexity – and individual capabilities – ability to process information, capacity to manage transaction costs, availability of private support – influence the benefits that individuals derive from choice. Results suggest that choice policies have an overall positive welfare effect in both health and long-term care. However, while direct evidence of outcome improvements is found, the empirical analysis only finds indirect evidence of procedural utility. Middle class characteristics, primarily income and education, are found to have a positive influence on the benefits of choice, amounting to evidence of inequitable facets of choice policies. The middle class further exhibits preferences for choice over and above other characteristics of health care systems. Overall, this thesis advocates a holistic approach to the analysis of choice, incorporating its procedural value and paying particular attention to the equity implications of the choice situation, information processing and differences in available options as well as preferences for choice

Informing and improving policy and practice for carers through research and evaluation

Carers Week took place last week to raise awareness and improve the lives of carers and the people they care for. Much has been said about the need for a robust evidence base to support this aim. Last year a seminar series funded by the Economic and Social Care Research Council explored some of the evidence and next steps; and there is a growing body of studies exploring different aspects of carers’ lives. Here PSSRU at LSE colleagues Valentina Zigante, Nicola Brimblecombe, and Derek King reflect on a joint workshop by the Social Services Research Group and the NIHR School for Social Care Research on how research and evaluation could inform and improve policy and practice in relation to informal carers

'The choice agenda' in European health systems: the role of 'middle class demands'

We examine the role of political economy drivers of the choice agenda in European health systems including middle class electoral support. Building on the reform trajectories and current institutional framework in eight western European countries where there have been significant choice reforms, we explore the preferences for choice and health system satisfaction in those countries. We find provider choice to be supported by middle class demands and health systems satisfaction, but weak evidence of other alternative political motivations for the expansion of provider choice. We conclude that in addition to efficiency improvements, provider choice is largely correlated with the demands for choice among the middle class. The provider choice agenda responds as much to political economy consideration as it does to efficiency arguments

Building ‘implicit partnerships’? Financial long-term care entitlements in Europe

The design of public subsidies for long-term care (LTC) programmes to support frail, elderly individuals in Europe is subject to both tight budget constraints and increasing demand preassures for care. However, what helps overcoming the constraints that modify LTC entitlements? We provide a unifying explanation of the conditions that facilitate the modification of public financial entitlements to LTC. We build on the concept of ‘implicit partnerships’, an implicit (or ‘silent’) agreement, encompassing the financial co-participation of both public funders, and families either by both allocating time and/or financial resources to caregiving. Next, we provide suggestive evidence of policy reforms modifying public entitlements in seven European countries which can be classified as either ‘implicit user partnerships’ or ‘implicit caregiver partnerships’. Finally, we show that taxpayers attitudes mirror the specific type of implicit partnership each country has adopted. Hence, we conclude that the modification of long-term care entitlements require the formation of some type of ‘implicit partnership'

Why the views of middle class citizens help explain increased choice in European healthcare systems

Several countries across Europe have attempted to reform their health systems by allowing patients more choice over their healthcare provider. The typical rationale for this strategy is that by creating competition between providers, there will be an increased incentive to improve the efficiency and quality of healthcare. Joan Costa-i-Font and Valentina Zigante assess the underlying factors that have led to European countries adopting this ‘choice agenda’ in their healthcare systems. They find that one of the key drivers for this type of reform has been the role of middle class citizens in demanding greater choice over health providers

'The choice agenda' in European health systems: the role of 'middle class demands'

We examine the role of political economy drivers of the choice agenda in European health systems including middle class electoral support. Building on the reform trajectories and current institutional framework in eight western European countries where there have been significant choice reforms, we explore the preferences for choice and health system satisfaction in those countries. We find provider choice to be supported by middle class demands and health systems satisfaction, but weak evidence of other alternative political motivations for the expansion of provider choice. We conclude that in addition to efficiency improvements, provider choice is largely correlated with the demands for choice among the middle class. The provider choice agenda responds as much to political economy consideration as it does to efficiency arguments

Changes in the balance between formal and informal care supply in England between 2001 and 2011: evidence from census data

Informal care plays a crucial role in the social care system in England and is increasingly recognised as a cornerstone of future sustainability of the long-term care (LTC) system. This paper explores the variation in informal care provision over time, and in particular, whether the considerable reduction in publicly-funded formal LTC after 2008 had an impact on the provision of informal care. We used small area data from the 2001 and 2011 English censuses to measure the prevalence and intensity (i.e. the number of hours of informal care provided) of informal care in the population. We controlled for changes in age structure, health, deprivation, income, employment and education. The effects of the change in formal social care provision on informal care were analysed through instrumental variable models to account for the well-known endogeneity. We found that informal care provision had increased over the period, particularly among high-intensity carers (20+ hours per week). We also found that the reduction in publicly-funded formal care provision was associated with significant increases in high-intensity (20+ hours per week) informal care provision, suggesting a substitutive relationship between formal and informal care of that intensity in the English system

The choice agenda in European health systems: the role of middle-class demands

Choice for patients, over varying aspects of healthcare, is becoming an increasingly common feature in Europe, especially in tax-funded healthcare systems. This paper investigates patients’ choice of healthcare provider. The middle class, in countries implementing choice reforms, is shown to have a pronounced preference for the availability of choice as a component of a quality healthcare system. Important implications of this for theory and policy are discussed

Different paths to the modern state in Europe: the interaction between domestic political economy and interstate competition

Theoretical work on state formation and capacity has focused mostly on early modern Europe and on the experience of western European states during this period. While a number of European states monopolized domestic tax collection and achieved gains in state capacity during the early modern era, for others revenues stagnated or even declined, and these variations motivated alternative hypotheses for determinants of fiscal and state capacity. In this study we test the basic hypotheses in the existing literature making use of the large date set we have compiled for all of the leading states across the continent. We find strong empirical support for two prevailing threads in the literature, arguing respectively that interstate wars and changes in economic structure towards an urbanized economy had positive fiscal impact. Regarding the main point of contention in the theoretical literature, whether it was representative or authoritarian political regimes that facilitated the gains in fiscal capacity, we do not find conclusive evidence that one performed better than the other. Instead, the empirical evidence we have gathered lends supports to the hypothesis that when under pressure of war, the fiscal performance of representative regimes was better in the more urbanized-commercial economies and the fiscal performance of authoritarian regimes was better in rural-agrarian economie