Estimating and explaining differences in income related inequality in health across general practices.

We use data on individual patients in general practices to examine whether income related inequality in self reported health differs across general practices and whether such differences are explained by characteristics of the practices. We allow for the simultaneous determination of health and income by instrumenting income. We also allow for item non response for the income question by a two stage selection model. We find that item non response has little effect on the estimated relationship between income and health but that allowing for simultaneity doubles the estimated effect of income on health. We show that there are significant differences in the effect of income on health across practices and that these differences are related to the number of patients per GP, a measure of practice prescribing quality, and the provision of out of hours services.Health; Income; Inequality; Primary care.

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.

Trends in health care commissioning in the English NHS: an empirical analysis

In recent years there have been marked changes in organisational structures and budgetary arrangements in the English NHS, potentially altering the relationships between purchasers (primary care organisations (PCOs) and general practices) and providers. Using data on elective hospital admissions from 1997/98 to 2002/03 we find that commissioning has become significantly more concentrated at PCO and GP level. There was a reduction in the average number of different providers used by PCOs (16.7 to 14.2), an increase in the average share of admissions accounted for by the main provider (49% to 69%), and an increase in the average Herfindahl index (0.35 to 0.55). About half the increase in concentration arose from the increase in the number of purchasing organisations from 100 to 302. The rest was due to mergers amongst providers and the abolition of fundholding. GP fundholding practices which held budgets for elective admissions had less concentrated admission patterns than non-fundholders whose admissions were paid for by their primary care organisation. There was an increase in concentration of admissions for both types of GP practice but fundholders used more providers, had smaller shares at their main provider, and had smaller Herfindahl indices.concentration, Herfindahl, purchasing, budgets, elective admissions

The Effects of Budgets on Doctors Behaviour: Evidence from a Natural Experiment

In many health care systems primary care physicians act as ‘gatekeepers’ to secondary care. We investigates the impact of the UK fundholding scheme under which general practices could elect to hold a budget to meet the costs of elective surgery for their patients. We use a differences in differences methodology on a large four year panel of English general practices before and after the abolition of fundholding. Fundholding incentives reduced fundholder elective admission rates by 3.3% and accounted for 57% of the difference between fundholder and nonfundholder elective admissions, with 43% a selection effect due to unobservable differences in practice characteristics. Fundholding had no effect on emergency admissions.budgets, health care, fundholding, admission rates

The Effect of Budgets on Doctor Behaviour: Evidence From A Natural Experiment

In many health care systems primary care physicians act as 'gatekeepers' to secondary care. We investigates the impact of the UK fundholding scheme under which general practices could elect to hold a budget to meet the costs of elective surgery for their patients. We use a differences in differences methodology on a large four year panel of English general practices before and after the abolition of fundholding. Fundholding incentives reduced fundholder elective admission rates by 3.3% and accounted for 57% of the difference between fundholder and nonfundholder elective admissions, with 43% a selection effect due to unobservable differences in practice characteristics. Fundholding had no effect on emergency admissions.Budgets; Health care; Fundholding; Admission rates

Does Better Disease Management in Primary Care Reduce Hospital Costs?

We apply cross-sectional and panel data methods to a database of 5 million patients in 8,000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.Quality; disease management; primary care; hospital costs; ambulatory care sensitive conditions; preventative care.

Addressing care-seeking as well as insurance-seeking selection biases in estimating the impact of health insurance on out-of-pocket expenditure

Health Insurance (HI) programmes in low-income countries aim to reduce the burden of individual out-of-pocket (OOP) health care expenditure. However, if the decisions to purchase insurance and to seek care when ill are correlated with the expected healthcare expenditure, the use of naïve models may produce biased estimates of the impact of insurance membership on OOP expenditure. Whilst many studies in the literature have accounted for the endogeneity of the insurance decision, the potential selection bias due to the care-seeking decision has not been taken into account. We extend the Heckman selection model to account simultaneously for both care-seeking and insurance-seeking selection biases in the healthcare expenditure regression model. The proposed model is illustrated in the context of a Vietnamese HI programme using data from a household survey of 1192 individuals conducted in 1999. Results were compared with those of alternative econometric models making no or partial allowance for selection bias. In this illustrative example, the impact of insurance membership on reducing OOP expenditures was underestimated by 21 percentage points when selection biases were not taken into account. We believe this is an important methodological contribution that will be relevant to future empirical work

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study.

OBJECTIVE: To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). DESIGN: Controlled longitudinal study. SETTING: English National Health Service between 1998/99 and 2010/11. PARTICIPANTS: Populations registered with each of 6975 family practices in England. MAIN OUTCOME MEASURES: Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. RESULTS: Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. CONCLUSIONS: The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities

Does better disease management in primary care reduce hospital costs? Evidence from English primary care

We apply cross-sectional and panel data methods to a database of 5 million patients in 8,000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.Quality. Disease management. Primary care. Hospital costs. Ambulatory care sensitive conditions. Preventative care.

Choosing and booking – and attending? Impact of an electronic booking system on outpatient referrals and non-attendances

An electronic booking system (Choose and Book – C&B) for general practices making hospital outpatient appointments was introduced in England in 2005 and by 2009 accounted for 50% of appointments. It was intended, inter alia, to reduce the rate of non-attendance at outpatient appointments (7.1% in 2004). We test whether it did so using a 2004-2009 panel with 7900 English general practices. We estimate that the use of C&B was associated with a reduction in non-attendances of 85,600 (15.8%) and a reduction in referrals of 358,000 (3%) in 2009