Effects of choice and market reform on inequalities of access to health care

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Effects of choice and market reform on
inequalities of access to health care

• Dr Richard CooksonSenior Lecturer and MRC
  FellowUniversity of York

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Effects of choice and market reform on
inequalities of access to health care
Funding body NHS RD Service, Delivery and
Organisation Programme Project duration 1
April 2007 - 31 March 2010 Host
institution University of York Lead
investigator Richard Cookson Co-applicants Mark
Dusheiko, Diane Dawson, Russell
Mannion Consultants Roy Carr-Hill, Hugh
Gravelle, Andrew Street, Geoffrey Hardman,
Steven Martin, Jake Abbas (YHPHO)
Department of Social Policy and Social Work The
York Management School Department of Economics
and Related Studies
Yorkshire Humber Public Health Observatory
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Background An Illustrative Example of
Pre-Existing NHS Inequality
The changing social gradient in elective hip
replacement in the English NHS, 1991 vs. 2001
(Age-sex standardised utilisation ratios by 50
Townsend deprivation quantiles of wards -
smoothed data)
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Research aims

• To quantify inequality trends in English NHS
  2001/2 to 2008/9, for
• All general categories of hospital activity
• A representative selection of diagnostic
  therapeutic procedures
• To test hypotheses about inequality effects of
  geographically varying aspects of choice and
  market reform, such as
• The local degree of choice / competition
• The local share of independent sector provision
• The local degree of financial pressure to close
  unprofitable services
• To test hypotheses about other factors driving
  inequality trends, such as
• Hospital supply factors (e.g. unit cost, length
  of stay)
• GP supply factors (e.g. GPs per head)

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Research limitations

• Focus on inequality between small areas
• Suitable national patient level data not
  available
• Focus on socio-economic inequality
• Will also examine age and ethnicity
• Hampered by changing relative needs (age) and
  poor data recording (ethnicity)
• Focus on inequality in use of care (activity)
• Not inequality in use of choice
• Will also examine inequality in waiting times and
  inequality in local supply of GPs/specialists/beds

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Hypotheses about links between health reform and
inequality

• Local service closures
• Disadvantaged patients may be less able to
  travel
• Perverse incentives in competitive areas
• creaming, skimping, and dumping
• Patient demand may outstrip need in affluent
  areas
• Activity skew towards profitable cure activity
• Away from complex, labour-intensive care
  activity
• (Tudor-Hart, J (2006) Political economy of
  health care p.18-19)