Effects of competition and incentives on productivity, quality and efficiency of NHS providers

The London School of Economics (LSE) research team comprises researchers from three research centres: LSE Health, Care Policy & Evaluation Centre (CPEC), and the LSE Research Laboratory (RLAB). The legal entity that LSE Health belongs to is London School of Economics, as LSE Health is a multidisciplinary research centre in advancing global research in health policy and health economics, based within the University. The research team will use HES (Hospital Episode Statistics) and PROMs (Patient Related Outcome Measures) and Civil Registration Data to make four distinct contributions to health and social care within a single programme of research. The first contribution is to analyse the impact that various aspects of policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. The second contribution compares health care system performance in several countries with the aim of spreading best practice across different countries, with specific focus on lessons that can be learnt for health and social care policy within the NHS. The third contribution develops and tests a range of multi-dimensional indicators of health care quality and outcomes. The fourth contribution analyses the link between population-level exposures to environmental shocks and health outcomes.

The purpose of receiving the NHS England Data is to analyse the impact of on-going NHS reforms implemented between 2000 and the present day using pseudonymised patient-level data (further details of these reforms are provided below). These reforms were primarily associated with the introduction of two Acts of Parliament (the National Health Service Act 2006 and the Health and Social Care Act 2012) that changed both the organisational and payment structures of the NHS. The second Act of Parliament relies on on-going productivity gains to maintain efficient NHS output. The objective of the research programme is to assess the change in policy direction arising from these reforms, to better understand the impact of these reforms on patient outcomes and to improve the measurement of the impact of these reforms and to aid the efficiency with which they are implemented.

London School of Economics requires access to an extract of Civil Registration mortality data because a key focus of the research is the effect of NHS reforms since 2000 on health care quality. LSE have produced many outputs that use mortality as an indicator of health care quality but have hitherto been limited to examining in-hospital mortality rather than all-location mortality because of no previous access to linked mortality data. The fact that LSE only have data on deaths in hospital has introduced a small but significant source of potential bias to previous work focusing on mortality. For instance, if some hospitals discharge patients earlier than others, then they might appear to offer higher care quality as captured by lower in-hospital mortality rates, when in fact patients from these hospitals are simply dying at home rather than in hospital. While previous work (see e.g., Cooper et al. 2011, Economic Journal) has carefully discussed this potential source of bias to show that it is unlikely to drive the findings, a more comprehensive solution to this problem is to obtain data on all-location mortality. Linking Civil Registration data to HES will enable LSE to henceforth use all-location mortality as an indicator of care quality. This will improve the quality of research and improve the ability of policymakers to confidently formulate policy changes aimed at improving health and social care that is informed by the findings of the research.

Research deliverables are currently underway to examine the impact of the following reforms to the NHS and include the following:

* Introduction of Payment by Results (2003-2006).

* Implementation of waiting time targets for first outpatient appointment, elective surgery, and A&E attendances (2001-2005).

* Introduction of the Quality and Outcomes Framework (2004).

* Introduction of patient choice of hospital and GP surgery (2006-2008).

* Introduction of independent care providers, both as part of the Independent Sector Treatment Centre programme and under the Any Qualified Provider programme (2003-2010).

* Introduction of Walk in Centres for ambulatory care (2000-2010).

* Introduction of the Alternative Provider of Medical Services GP contract (2004).

* Expansion of primary care provision under the Equitable Access to Primary Care initiative (2007-2010).

* Introduction of Clinical Commissioning Groups in place of Primary Care Trusts (2013-2014).

* Progress towards the Nicholson productivity challenge (2009-2015).

* Introduction of new signals of hospital outcomes and performance, including the NHS Choices website (2006), Patient Reported Outcome Measures (2009), the NHS Staff Survey (2003), and various NHS Patient Satisfaction and Patient Experience surveys.

Each of these research deliverables form part of the first contribution to health and social care outlined above, by analysing a specific policy introduced within the NHS over the last 15 years. Each of these deliverables also forms part of the third contribution to health and social care, in that each focuses on analysing the impact of a particular policy or reform on one or more multi-dimensional indicators of health care quality and outcomes.

The research team has primarily progressed the second contribution to health and social care – a cross-country comparison of health care system performance – via a project entitled “Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” that examines the impact of financial incentives on clinicians’ decisions in England and Scotland. Making further progress toward this second contribution to health and social care will be a major focus of the research programme over the next 2-3 years.

The research team intends to progress the fourth contribution to health and social care – analysing health responses to population-level exposures to environmental shocks such as pollution. A key aim of this fourth contribution is to estimate the causal relationship between ambient air pollution and hospital admissions. Another objective of this fourth contribution is to evaluate the health impact of the London Congestion Charge via changes in air quality in the London area. Specifically, the research team intend to investigate whether the introduction of the Congestion Charge and the subsequent change in air quality in London decreased the frequency and duration of hospital admissions for pollution-related diseases, particularly among sensitive groups such as infants and the elderly.

Using patient-level data is necessary for risk adjustment at the patient level, thereby allowing control of confounding factors that will affect the analysis. Using patient-level data is also necessary to construct various inputs into the analysis -- for example, percentiles of distance from patient's GP surgery to hospital of admission, which are needed to construct indices that define hospital referral markets and potential areas of competition. All programme outputs that have used data NHS England has provided have been aggregated with small number suppression in line with the HES analysis guide.

A significant portion of the research programme involves assessment of NHS reforms initiated during the first decade of the 2000s. To effectively assess these reforms, not only is data from these years required, but also, data from the pre-reform period is required, in order to establish a baseline against which subsequent health care provider behaviour and performance can be compared. For this reason, it is crucial to have data from 1996/1997 onwards.

Another core focus of the research programme is to assess efforts to increase NHS productivity in the years since 2010. These efforts were initially linked to the ’Nicholson challenge’ to find £20 billion in efficiency savings by 2015 but have continued since then in light of continued pressures on NHS funding. In order to pursue this aspect of LSE’s research programme, data from 2009/10 to the present are required.

A large number of the outputs produced as part of this research programme examine mortality as an outcome variable. HES provides data in deaths in hospital, but it does not provide data on deaths subsequent to discharge. Studies that examine mortality using only HES always face questions about the potential that their results are biased by the exclusive focus on in-hospital deaths, as the pattern of all-location mortality may be different to the pattern of in-hospital mortality. Linking HES data to mortality data will provide this research team with a comprehensive means of eliminating this potential source of bias, by allowing them to analyse all-location mortality rather than in-hospital mortality.

The request for data primarily pertains to the first purpose (analysing the impact of various aspects of policy-development and reform of the NHS), in the manner described below. Access to more recent years of data will also enable LSE to further the fourth purpose (analysing the link between population-level exposures to environmental shocks and health outcomes) by enabling this analysis to be conducted using up-to-date data.

The first purpose is designed to inform current policy requirements. The more contemporaneous the data is, the better LSE can achieve this objective. The most recent years have also seen the greatest financial constraints, even accounting for some uplift payments, and the research team are most interested in documenting how the NHS has coped under this financial stringency. Below LSE outline three key areas where access to new years of data will be of particular value.

One policy implication of tightening budgets is in the interface between NHS hospital performance and the community care provided by Local Authorities. One strand of the on-going research on productivity, which will continue under a renewed grant from the Department of Health and Social Care (DHSC) to the LSE (and LSE have already presented some early results of this work to the DHSC), is concerned with how hospital discharge decisions are affected by the supply constraints faced by Local Authorities with regards to the provision of community care services. If there is insufficient supply of care in the community then, regardless of the efficiency gains achieved by hospitals in their discharge processes, bed-blocking will still occur. LSE require up-to-date HES data to document how these relationships have evolved under recent changes to NHS finances. LSE's aim is that this research will identify how the NHS and Local Authorities can coordinate care provision more effectively, thus contributing to improved hospital performance and more joined-up care.

A second strand of the first research purpose is examining patient choice as a means of delivering high quality health care within the NHS, as is articulated in the NHS Constitution. In particular, LSE are empirically analysing how patients and their GPs make elective surgery referral choices, and what specific signals of provider quality they react to. The research team know and can already document that waiting time for elective surgery has a major impact on choice of hospital. Over the past few years, waiting time targets have been missed by many providers. LSE will supplement existing work on patient choice to investigate how these missed targets have affected patient choice. LSE are particularly interested in assessing whether access to care for individuals in the most deprived areas has been more adversely affected by worsening targets, and whether there has been a measurable impact on health outcomes as a consequence. Access to data for more recent years, when achievement of waiting time targets has worsened considerably, is necessary to undertake this investigation.

A third strand of investigation necessitating up-to-date data relates to interest in productivity through an analysis of the up-take and diffusion of new health care technologies. In particular, LSE are examining how new technology either substitutes or complements existing technology. As referenced by the UK Office for Budget Responsibility (Fiscal Sustainability and Public Health Spending, September 2016), earlier work by LSE using HES data on two common surgical procedures (angioplasty and coronary artery bypass grafting) has shown that technological innovations are generally cost-escalating rather than cost-containing. LSE are in the process of extending this work to consider implications for labour input choices — both substitution between labour and capital, and substitution between different types of labour (physician specialities). LSE require access to new data to examine the diffusion of new health care technologies since 2014/15.

An aspect of this work is funded by The Health Foundation. The Health Foundation work is contributing to the first research purpose which is on the impact that policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. LSE are linking the up-take of new technology as guided by policy-development and assessing the impact that it has on new surgical procedures, patient outcomes and provider behaviour. Specifically, LSE are considering the regulatory support for new surgical procedures as these new procedures will affect patient outcomes and provider behaviour, in this specific case the impact will be on provider workforce composition.

LSE have taken surgical procedures and related this to the impact on the NHS workforce by considering whether the surgical composition has changed as a result of the policy support, through NHS and NICE guidance, for new surgical techniques. For example, LSE are currently looking at the impact on provider behaviour, in terms of workforce composition, as Percutaneous Transluminal Coronary Angioplasty (PTCA) has replaced Coronary Artery Bypass Grafting (CABG).

LSE are the sole Controller who also processes the data.

The lawful basis for processing personal data under the UK GDPR is Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

The lawful basis for processing special category data under the UK GDPR is Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

The processing is in the interest of the public as seeks to measure the impact of implemented policies and reform, performance, multi-dimensional indicators, population-level exposures to environmental shocks, and how that effects patients involved.

Amazon Web Services (AWS) provides IT hosting services to LSE and will store the NHS Egnland Data as contracted by LSE.

The expected outputs consist of research reports and published papers, and discussions and presentations to UK health and social care policymakers, policy analysts, and clinicians. A list of outputs to date is provided below. The primary target audience for these outputs is the health policy community. This includes policymakers, as a key aim of the research is to investigate the impact of recent changes to health and social care policy, with an ultimate objective of influencing future policy formation. However, it also includes other policy analysts, such as (but not limited to) those at the Health Foundation, the King’s Fund and Nuffield Trust, who, while they may not be directly involved in the policy formation process, do have an important influence over the terms under which health policy is debated and therefore formulated.

A secondary target audience is the medical community that has been responsible for implementing many of the policy reforms analysed, and whose decisions therefore determine the success of these reforms, and the nature of their impacts.

Another secondary target audience for the team's fourth contribution, on the link between population-level exposures to environmental shocks and health outcomes, is environmental policymakers -- for example those responsible for air pollution regulations. This fourth contribution aims to benefit health and social care by providing more rigorous evidence than is currently available concerning the effects on population health of environmental policies such as the London Congestion charge and the T-charge (emissions surcharge).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reform and health and social care outcomes. A few of these variables (e.g. whether a patient is discharged as dead) appear directly in HES, but most (e.g. length of hospital stay, patient severity aggregating across multiple diagnoses, hospital productivity, or intensity of competition to which a hospital is exposed) are constructed using multiple underlying HES variables. HES data will only feature directly in the outputs of these research projects in tables of summary statistics that report properties of key variables used in the analysis (such as minimum, maximum, and average values).

No data or datasets using HES data will be published or made available, either at the individual patient level or at an aggregate level, as part of this programme of work. The data will not be used for any commercial purpose.

LSE hope to improve all such research by using the civil registration data to henceforth examine all-location mortality rather than in-hospital mortality.

A key part of the research programme is to assess the impact of the Health and Social Care Act 2012, and interrelated reforms. Examples of changes associated with this legislation that are being assessed include:

• 2012 introduction of Any Qualified Provider.

• 2013 introduction of Clinical Commissioning Groups.

• 2015 introduction of patient choice of General Practitioner.

• Phases 1 and 2 of the Quality, Innovation, Productivity and Prevention (QIPP).

• Effects of NHS contracting reforms on the relationship between hospital trusts and Local Authorities, with a particular focus on effects on bed blocking.

To assess these reforms, the research team require years of data from after their implementation. Many changes resulting from this legislation did not take effect until April 2013 and their full impact was not felt until some time after that. Obtaining data up to 2022/2023 will enable a comprehensive assessment of the impact of these reforms over time.

Several project outputs are already available in draft form which have been published , and further outputs are expected to be published in final form over the next 3 years. Draft papers are largely for internal academic discussion and review with a view to improving methodology and interpretation of results. The ongoing results of this work are presented below under the headings “First application summary”, “Update October 2017”, “Update November 2022” which reflect the progress as LSE have continued the ongoing work.

First application summary:

Draft project outputs already produced

In this field of work, the life cycle of a research project can be roughly summarised as follows: work in progress presentation (slides only); unpublished mimeo; Working Paper (which may also be a final output, or may be progressed to academic journal submission); submission to academic journal (if relevant); and publication of final report or journal article. Irrespective of the final publication location, the research team takes substantial effort to disseminate its outputs by presenting findings to policymakers and policy analysts.

The following research projects are at work in progress stage:

•“Taking care of the budget? Clinical decisions and Patient Outcomes under recent NHS reforms”.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”.

• “Home for the Holidays: Evidence on the Relationship Between Prospective Payment, Length of Stay, and Patient Outcomes”.

The following research projects are at mimeo stage

•“The hospital as a multi-product firm: Measuring the effect of hospital competition on quality using Patient-Reported Outcome Measures”.

• “Independent Sector Treatment Centres in the English NHS: Effects on neighbouring NHS hospitals”.

The following research projects are at Working Paper stage:

•“Walk This Way: Estimating Impacts of Walk in Centres at Hospital Emergency Departments in the English National Health Service”, SERC Discussion Paper 167, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0167.pdf.

• “Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service”, CEP Discussion Paper 1125,

http://cep.lse.ac.uk/pubs/download/dp1125.pdf.

The following papers are under review for academic journal publication:

•“Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” (for slides see: http://www.slideshare.net/OHENews/do-financial-incentives-trump-clinical-guidance-apr15).

• “Measuring and Forecasting Hospital Quality”.

Dissemination of draft project outputs

This is a non-exhaustive list of the formal and informal methods by which the Research Team has disseminated their draft project outputs to policymakers, policy analysts and clinicians.

Since 2013, draft outputs of the research projects have been disseminated directly to policymakers in the following ways:

• Seminar presentation to Department of Health, July 2015.

• Seminar presentation to Office of Health Economics, May 2015 (attended by representatives from Monitor and Department of Health).

• Presentation of research to Department of Health group, March 2015.

• Multiple meetings to report draft project outputs to representatives of Monitor and Department of Health.

In addition, the draft project outputs have been presented to the following fora that have been attended by policymakers and policy analysts:

• Health Economics Study Group (January 2015 and June 2016).

• Royal Economics Society Meeting (March 2015).

• LSE Spatial Economics Research Centre Conference (March 2015).

• LSE STICERD Work in Progress Seminar (October 2013) (attended by representatives of Royal College of Surgeons).

• Informal workshop involving representatives from King’s Fund, and former Prime Ministerial advisors and heads of regulatory bodies (June 2015).

• Joint LSE-Dartmouth College workshop on Medical Practice Variations (September 2014).

• LSE International Health Policy Conference 2017.

Finally, the research outputs have been reported in media sources widely read by health policymakers and thought leaders, including (this is a very incomplete list) the Health Services Journal, The Guardian, The New Statesman, The Daily Telegraph, and The Financial Times.

Update October 2017:

New Work in Progress

•“The relationship between new technologies and workforce in English hospitals”, October.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”, April.

• “Patients’ choice and hospital quality competition: Unintended impacts of the signals”, October.

• “Coordinating Hospital Discharges: Bed Blocking in England”, October.

New Working Papers:

• “Taking Care of the Budget? Practice-level Outcomes during Commissioning Reforms in England”, SERC Discussion Paper 192, February, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0192.pdf.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service” CEP Discussion Paper 1434, June, http://cep.lse.ac.uk/pubs/download/dp1434.pdf.

• “The Hospital as a Multi-Product Firm: The Effect of Hospital Competition on Value-Added Indicators of Clinical Quality” CEP Discussion Paper 1484, May, http://cep.lse.ac.uk/pubs/download/dp1484.pdf.

New academic journal publications:

• “Coordinating Hospital Discharges: Bed Blocking in England”, Journal of Health Economics, accepted subject to revisions.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service”, Journal of Public Economics, accepted subject to revisions

•“Measuring and forecasting quality in English hospitals”, Journal of the Royal Statistical Society: Series A 180(2), February, pp.409-432, ISSN 0964-1998.

•“Do financial incentives trump clinical guidance? Hip replacement in England and Scotland”, Journal of Health Economics 44, pp.25-36, ISSN 0167-6296.

Since 2015, LSE have disseminated their research to individual contacts in NHS Improvement, Department of Health, the Department of Health's Economics of Social and Health Care Research Unit, the Competition and Markets Authority, and the Health Foundation.

In 2015, LSE presented their research on the tension between financial incentives and clinical guidance to a UK Government Department of Health Seminar.

In September 2015, LSE presented their research on the impacts of hospital competition to the Wennberg International Collaborative on unwarranted variations in health care utilisation and outcomes. This high-level forum included representatives from Monitor/ NHS Improvement, NHS England, and NHS Scotland, as well as senior representatives from other health care systems around the world.

In November 2016, LSE presented their research on the impact of new medical technologies within the NHS to the Health Foundation. This was a stepping stone to disseminating this research more widely to policymakers and the broader health policy community.

In May 2017, at the invitation of the UK Competition and Markets Authority (CMA), LSE presented their research on the impacts of hospital competition to an international conference of European competition regulators. The research team's findings have a direct impact on the decision-making process of competition regulators such as the CMA concerning hospital mergers. The LSE presented its findings to representatives of the following organisations:

• From the UK: the Competition and Markets Authority and NHS Improvement.

• From the Netherlands: the Authority for Competition and Markets, the Dutch Healthcare Authority, and the Ministry of Health.

• From Norway: the Competition Authority.

• From Germany: Bundeskartellamt (Federal Cartel Office).

• From France: Autorité de la concurrence (Competition Authority).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reforms and environmental shocks with health and social care outcomes.

Update November 2022:

New work in progress, not yet published:

• “Volume-outcome relationship in critically ill patients in the UK”, March 2021

• “Comparing the dangers of a hospital stay at public and private hospitals in England”, August 2021

• “Comparing health inequalities leading up to and during the first wave of Covid pandemic in England and Canada”, June 2022

• “Understanding the trajectory of frailty across the life course”, June 2022.

• “The impact of workforce turnover and temporary staff on productivity and health outcomes in the hospital sector”, September 2022

New working papers:

• “Exploring the Impact of New Medical Technology on Workforce Planning”, 2019

https://openaccess.city.ac.uk/id/eprint/22243/

• “Does choice and competition in Public Services Improve the Performance of Non-Altruistic Providers, but Worsen the Performance of Altruistic Providers?”, 2019 https://personal.lse.ac.uk/skellern/Research_files/Altruism_Competition.pdf

• “The Effect of Hospital Competition on Value-Added Indicators of Elective Surgery Quality”, 2019

http://personal.lse.ac.uk/skellern/Research_files/PROMs_comp_paper.pdf

New academic journal publications:

• “Hospital coordination and integration with social care in England: The effect on post-operative length of stay”, published in Journal of Health Economics, 2018. https://doi.org/10.1016/j.jhealeco.2018.02.005

• “Convenient primary care and emergency hospital utilisation”, published in Journal of Health Economics 2019. https://doi.org/10.1016/j.jhealeco.2019.102242

• “Impact of austerity on opioid abuse in England”, published in Social Science and Medicine, 2021 https://doi.org/10.1016/j.socscimed.2021.114511

• “Comparing the dangers of a day in English and German hospitals for high-need patients”, published in Health Services Research, 2021 https://doi.org/10.1111/1475-6773.13712

• “The diffusion of robotic surgery: Examining technology use in the English NHS”, published in the Journal of Health Policy, 2022 https://doi.org/10.1016/j.healthpol.2022.02.007

The main outcome of the presentation at the Wennberg International Collaborative was simply to raise awareness about the research findings amongst policymakers and practitioners.

Earlier work compiled by the research team (Cooper et al 2011) was cited by the then Prime Minister in support of the Health and Social Care Act 2012, which expanded choice and competition within the NHS. The research also helped to ensure that these reforms did not introduce price competition between health care providers, as had initially been proposed. The work on hospital quality and on choice and competition has been used by NHS Monitor (now NHS Improvement) in their measurement and analysis of hospital efficiency measurement, which forms one strand of their work to identify inefficient hospital trusts. The project lead has since worked with NHS Improvement to aid this strand of their work, and the work in this area also led to him becoming an adviser to the UK Competition and Markets Authority investigation into the Private Health Care Market which led to a range of measures being implemented in 2014 (see https://www.gov.uk/cma-cases/private-healthcare-market-investigation).

October 2020~:

The London School of Economics have continued working on patient choice models, competition and productivity with and increasing share of work moving to productivity as the policy perspective within the NHS changes. Below are a list of recent deliverables coming from the use of data received under DARS-NIC-354497.

Listed below are the outputs delivered since the last DSA update in mid 2019.

1) ROBOTS

a) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). How robots diffuse: a description of technology use in the English NHS. (submitted to SS&M)

b) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). The Creep of the Robots. (to be submitted soon).

Prize for the best paper ("The creep of the robots") presented at the Spanish Health Economics Association Meeting, University of Castilla la Mancha, Albacete (2019) by a young researcher. Funded by "Cátedra CaixaBank-Fedea".

Presented at:

- Department of Applied Economics, Universitat Autónoma de Barcelona (UAB), Spain, 28th May 2020.

- NHS Improvement - Economics Community Seminar, NHS England, 21st May 2020.

- Department of Health Policy Seminars, LSE, London. January 2020.

- Department of Economics, Universitat de Barcelona (UB), Spain, 6th November 2019.

- UK Health Economists Study Group (HESG) Meeting, University of East Anglia, UK, 26th-28th June 2019.

- Spanish Health Economics Association Meeting, Universidad de Castilla la Mancha, Albacete, Spain, 11th-14th June 2019.

- VIII Taller EvaluAES, University of Illes Balears, Spain, 2nd May 2019.

2) PTCA/CABG

Maynou, L; McGuire, A; Serra-Sastre, V. (2020). Exploring the impact of new medical technology on workforce planning. (to be submitted soon).

Working paper version – City, University of London, 2019:

https://openaccess.city.ac.uk/id/eprint/22243/1/Dept_Econ_WP1907%20%28002%29.pdf

Update December 2022:

The updates on further papers and their presentations since the last submission are described above in the Outputs section previously.

LSE researchers presented their work on the impact of new technology on workforce planning to NHS England and NHS Improvement in April 2019. The work had previously been discussed at several health economic conferences and research institutes. This work is beginning to be recognised as a fundamental contribution to understanding the impact of technology dissemination on the NHS workforce. It has pioneered the estimation of labour substitutability or complementarity within the NHS as new technology is taken up. It has fed in to the Health Foundation initiative, based around the Department of Public Health at the University of Cambridge, where a workshop was run that included a large number of NHS managers concerning technology uptake and labour substitutability. In this way it has helped to disseminate best practice concerning technology uptake within the NHS.

Continuing these discussions with NHS England on new technologies, the work on technology diffusion (“creep of the robots”) was discussed with NHS Improvement/NHS England at their Economics Community Seminar on 21 May 2020. The work has previously been discussed and results shared at various health policy conferences.

The work on “convenient primary care and emergency hospital utilisation” was presented to NHS England in July 2019, the results having been discussed previously with various NHS commissioners. The piece was discussed in the HSJ that year.

The working paper on the effect of competition on altruistic and non-altruistic providers was discussed member of government Behavioural Insights Team, focusing on its implications for market-based public sector reforms. In July 2018, LSE researchers met with members of NHS Improvement Economics Team, focusing on how the paper's measures of management altruism/ intrinsic motivation related to aspects of trust performance/ behaviour measured by regulators (NHS Improvement and Care Quality Commission). This and the above programmes of work are included to demonstrate our ongoing engagement with policymakers, particularly at NHS England, but as they are relatively recent presentations, we are not yet able to report yielded benefits.

The London School of Economics (LSE) research team comprises researchers from three research centres: LSE Health, Care Policy & Evaluation Centre (CPEC), and the LSE Research Laboratory (RLAB). The legal entity that LSE Health belongs to is London School of Economics, as LSE Health is a multidisciplinary research centre in advancing global research in health policy and health economics, based within the University. The research team will use HES (Hospital Episode Statistics) and PROMs (Patient Related Outcome Measures) and Civil Registration Data to make four distinct contributions to health and social care within a single programme of research. The first contribution is to analyse the impact that various aspects of policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. The second contribution compares health care system performance in several countries with the aim of spreading best practice across different countries, with specific focus on lessons that can be learnt for health and social care policy within the NHS. The third contribution develops and tests a range of multi-dimensional indicators of health care quality and outcomes. The fourth contribution analyses the link between population-level exposures to environmental shocks and health outcomes.

The purpose of receiving the data is to analyse the impact of on-going NHS reforms implemented between 2000 and the present day using pseudonymised patient-level data (further details of these reforms are provided below). These reforms were primarily associated with the introduction of two Acts of Parliament (the National Health Service Act 2006 and the Health and Social Care Act 2012) that changed both the organisational and payment structures of the NHS. The second Act of Parliament relies on on-going productivity gains to maintain efficient NHS output. The objective of the research programme is to assess the change in policy direction arising from these reforms, to better understand the impact of these reforms on patient outcomes and to improve the measurement of the impact of these reforms and to aid the efficiency with which they are implemented.

London School of Economics requires access to an extract of Civil Registration mortality data because a key focus of the research is the effect of NHS reforms since 2000 on health care quality. LSE have produced many outputs that use mortality as an indicator of health care quality but have hitherto been limited to examining in-hospital mortality rather than all-location mortality because of no previous access to linked mortality data. The fact that LSE only have data on deaths in hospital has introduced a small but significant source of potential bias to previous work focusing on mortality. For instance, if some hospitals discharge patients earlier than others, then they might appear to offer higher care quality as captured by lower in-hospital mortality rates, when in fact patients from these hospitals are simply dying at home rather than in hospital. While previous work (see e.g., Cooper et al. 2011, Economic Journal) has carefully discussed this potential source of bias to show that it is unlikely to drive the findings, a more comprehensive solution to this problem is to obtain data on all-location mortality. Linking Civil Registration data to HES will enable LSE to henceforth use all-location mortality as an indicator of care quality. This will improve the quality of research and improve the ability of policymakers to confidently formulate policy changes aimed at improving health and social care that is informed by the findings of the research.

Research deliverables are currently underway to examine the impact of the following reforms to the NHS and include the following:

* Introduction of Payment by Results (2003-2006).

* Implementation of waiting time targets for first outpatient appointment, elective surgery, and A&E attendances (2001-2005).

* Introduction of the Quality and Outcomes Framework (2004).

* Introduction of patient choice of hospital and GP surgery (2006-2008).

* Introduction of independent care providers, both as part of the Independent Sector Treatment Centre programme and under the Any Qualified Provider programme (2003-2010).

* Introduction of Walk in Centres for ambulatory care (2000-2010).

* Introduction of the Alternative Provider of Medical Services GP contract (2004).

* Expansion of primary care provision under the Equitable Access to Primary Care initiative (2007-2010).

* Introduction of Clinical Commissioning Groups in place of Primary Care Trusts (2013-2014).

* Progress towards the Nicholson productivity challenge (2009-2015).

* Introduction of new signals of hospital outcomes and performance, including the NHS Choices website (2006), Patient Reported Outcome Measures (2009), the NHS Staff Survey (2003), and various NHS Patient Satisfaction and Patient Experience surveys.

Each of these research deliverables form part of the first contribution to health and social care outlined above, by analysing a specific policy introduced within the NHS over the last 15 years. Each of these deliverables also forms part of the third contribution to health and social care, in that each focuses on analysing the impact of a particular policy or reform on one or more multi-dimensional indicators of health care quality and outcomes.

The research team has primarily progressed the second contribution to health and social care – a cross-country comparison of health care system performance – via a project entitled “Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” that examines the impact of financial incentives on clinicians’ decisions in England and Scotland. Making further progress toward this second contribution to health and social care will be a major focus of the research programme over the next 2-3 years.

The research team intends to progress the fourth contribution to health and social care – analysing health responses to population-level exposures to environmental shocks such as pollution. A key aim of this fourth contribution is to estimate the causal relationship between ambient air pollution and hospital admissions. Another objective of this fourth contribution is to evaluate the health impact of the London Congestion Charge via changes in air quality in the London area. Specifically, the research team intend to investigate whether the introduction of the Congestion Charge and the subsequent change in air quality in London decreased the frequency and duration of hospital admissions for pollution-related diseases, particularly among sensitive groups such as infants and the elderly.

Using patient-level data is necessary for risk adjustment at the patient level, thereby allowing control of confounding factors that will affect the analysis. Using patient-level data is also necessary to construct various inputs into the analysis -- for example, percentiles of distance from patient's GP surgery to hospital of admission, which are needed to construct indices that define hospital referral markets and potential areas of competition. All programme outputs that have used data NHS England has provided have been aggregated with small number suppression in line with the HES analysis guide.

A significant portion of the research programme involves assessment of NHS reforms initiated during the first decade of the 2000s. To effectively assess these reforms, not only is data from these years required, but also, data from the pre-reform period is required, in order to establish a baseline against which subsequent health care provider behaviour and performance can be compared. For this reason, it is crucial to have data from 1996/1997 onwards.

Another core focus of the research programme is to assess efforts to increase NHS productivity in the years since 2010. These efforts were initially linked to the ’Nicholson challenge’ to find £20 billion in efficiency savings by 2015 but have continued since then in light of continued pressures on NHS funding. In order to pursue this aspect of LSE’s research programme, data from 2009/10 to the present are required.

A large number of the outputs produced as part of this research programme examine mortality as an outcome variable. HES provides data in deaths in hospital, but it does not provide data on deaths subsequent to discharge. Studies that examine mortality using only HES always face questions about the potential that their results are biased by the exclusive focus on in-hospital deaths, as the pattern of all-location mortality may be different to the pattern of in-hospital mortality. Linking HES data to mortality data will provide this research team with a comprehensive means of eliminating this potential source of bias, by allowing them to analyse all-location mortality rather than in-hospital mortality.

The request for data primarily pertains to the first purpose (analysing the impact of various aspects of policy-development and reform of the NHS), in the manner described below. Access to more recent years of data will also enable LSE to further the fourth purpose (analysing the link between population-level exposures to environmental shocks and health outcomes) by enabling this analysis to be conducted using up-to-date data.

The first purpose is designed to inform current policy requirements. The more contemporaneous the data is, the better LSE can achieve this objective. The most recent years have also seen the greatest financial constraints, even accounting for some uplift payments, and the research team are most interested in documenting how the NHS has coped under this financial stringency. Below LSE outline three key areas where access to new years of data will be of particular value.

One policy implication of tightening budgets is in the interface between NHS hospital performance and the community care provided by Local Authorities. One strand of the on-going research on productivity, which will continue under a renewed grant from the Department of Health and Social Care (DHSC) to the LSE (and LSE have already presented some early results of this work to the DHSC), is concerned with how hospital discharge decisions are affected by the supply constraints faced by Local Authorities with regards to the provision of community care services. If there is insufficient supply of care in the community then, regardless of the efficiency gains achieved by hospitals in their discharge processes, bed-blocking will still occur. LSE require up-to-date HES data to document how these relationships have evolved under recent changes to NHS finances. LSE's aim is that this research will identify how the NHS and Local Authorities can coordinate care provision more effectively, thus contributing to improved hospital performance and more joined-up care.

A second strand of the first research purpose is examining patient choice as a means of delivering high quality health care within the NHS, as is articulated in the NHS Constitution. In particular, LSE are empirically analysing how patients and their GPs make elective surgery referral choices, and what specific signals of provider quality they react to. The research team know and can already document that waiting time for elective surgery has a major impact on choice of hospital. Over the past few years, waiting time targets have been missed by many providers. LSE will supplement existing work on patient choice to investigate how these missed targets have affected patient choice. LSE are particularly interested in assessing whether access to care for individuals in the most deprived areas has been more adversely affected by worsening targets, and whether there has been a measurable impact on health outcomes as a consequence. Access to data for more recent years, when achievement of waiting time targets has worsened considerably, is necessary to undertake this investigation.

A third strand of investigation necessitating up-to-date data relates to interest in productivity through an analysis of the up-take and diffusion of new health care technologies. In particular, LSE are examining how new technology either substitutes or complements existing technology. As referenced by the UK Office for Budget Responsibility (Fiscal Sustainability and Public Health Spending, September 2016), earlier work by LSE using HES data on two common surgical procedures (angioplasty and coronary artery bypass grafting) has shown that technological innovations are generally cost-escalating rather than cost-containing. LSE are in the process of extending this work to consider implications for labour input choices — both substitution between labour and capital, and substitution between different types of labour (physician specialities). LSE require access to new data to examine the diffusion of new health care technologies since 2014/15.

An aspect of this work is funded by The Health Foundation. The Health Foundation work is contributing to the first research purpose which is on the impact that policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. LSE are linking the up-take of new technology as guided by policy-development and assessing the impact that it has on new surgical procedures, patient outcomes and provider behaviour. Specifically, LSE are considering the regulatory support for new surgical procedures as these new procedures will affect patient outcomes and provider behaviour, in this specific case the impact will be on provider workforce composition.

LSE have taken surgical procedures and related this to the impact on the NHS workforce by considering whether the surgical composition has changed as a result of the policy support, through NHS and NICE guidance, for new surgical techniques. For example, LSE are currently looking at the impact on provider behaviour, in terms of workforce composition, as Percutaneous Transluminal Coronary Angioplasty (PTCA) has replaced Coronary Artery Bypass Grafting (CABG).

LSE are the sole Data Controller who also processes the data.

The lawful basis for processing personal data under the UK GDPR is:

Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

The lawful basis for processing special category data under the UK GDPR is:

Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

The processing is in the interest of the public as seeks to measure the impact of implemented policies and reform, performance, multi-dimensional indicators, population-level exposures to environmental shocks, and how that effects patients involved.

The expected outputs consist of research reports and published papers, and discussions and presentations to UK health and social care policymakers, policy analysts, and clinicians. A list of outputs to date is provided below. The primary target audience for these outputs is the health policy community. This includes policymakers, as a key aim of the research is to investigate the impact of recent changes to health and social care policy, with an ultimate objective of influencing future policy formation. However, it also includes other policy analysts, such as (but not limited to) those at the Health Foundation, the King’s Fund and Nuffield Trust, who, while they may not be directly involved in the policy formation process, do have an important influence over the terms under which health policy is debated and therefore formulated.

A secondary target audience is the medical community that has been responsible for implementing many of the policy reforms analysed, and whose decisions therefore determine the success of these reforms, and the nature of their impacts.

Another secondary target audience for the team's fourth contribution, on the link between population-level exposures to environmental shocks and health outcomes, is environmental policymakers -- for example those responsible for air pollution regulations. This fourth contribution aims to benefit health and social care by providing more rigorous evidence than is currently available concerning the effects on population health of environmental policies such as the London Congestion charge and the T-charge (emissions surcharge).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reform and health and social care outcomes. A few of these variables (e.g. whether a patient is discharged as dead) appear directly in HES, but most (e.g. length of hospital stay, patient severity aggregating across multiple diagnoses, hospital productivity, or intensity of competition to which a hospital is exposed) are constructed using multiple underlying HES variables. HES data will only feature directly in the outputs of these research projects in tables of summary statistics that report properties of key variables used in the analysis (such as minimum, maximum, and average values).

No data or datasets using HES data will be published or made available, either at the individual patient level or at an aggregate level, as part of this programme of work. The data will not be used for any commercial purpose.

LSE hope to improve all such research by using the civil registration data to henceforth examine all-location mortality rather than in-hospital mortality.

A key part of the research programme is to assess the impact of the Health and Social Care Act 2012, and interrelated reforms. Examples of changes associated with this legislation that are being assessed include:

• 2012 introduction of Any Qualified Provider.

• 2013 introduction of Clinical Commissioning Groups.

• 2015 introduction of patient choice of General Practitioner.

• Phases 1 and 2 of the Quality, Innovation, Productivity and Prevention (QIPP).

• Effects of NHS contracting reforms on the relationship between hospital trusts and Local Authorities, with a particular focus on effects on bed blocking.

To assess these reforms, the research team require years of data from after their implementation. Many changes resulting from this legislation did not take effect until April 2013 and their full impact was not felt until some time after that. Obtaining data up to 2022/2023 will enable a comprehensive assessment of the impact of these reforms over time.

Several project outputs are already available in draft form which have been published , and further outputs are expected to be published in final form over the next 3 years. Draft papers are largely for internal academic discussion and review with a view to improving methodology and interpretation of results. The ongoing results of this work are presented below under the headings “First application summary”, “Update October 2017”, “Update November 2022” which reflect the progress as LSE have continued the ongoing work.

First application summary:

Draft project outputs already produced

In this field of work, the life cycle of a research project can be roughly summarised as follows: work in progress presentation (slides only); unpublished mimeo; Working Paper (which may also be a final output, or may be progressed to academic journal submission); submission to academic journal (if relevant); and publication of final report or journal article. Irrespective of the final publication location, the research team takes substantial effort to disseminate its outputs by presenting findings to policymakers and policy analysts.

The following research projects are at work in progress stage:

•“Taking care of the budget? Clinical decisions and Patient Outcomes under recent NHS reforms”.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”.

• “Home for the Holidays: Evidence on the Relationship Between Prospective Payment, Length of Stay, and Patient Outcomes”.

The following research projects are at mimeo stage

•“The hospital as a multi-product firm: Measuring the effect of hospital competition on quality using Patient-Reported Outcome Measures”.

• “Independent Sector Treatment Centres in the English NHS: Effects on neighbouring NHS hospitals”.

The following research projects are at Working Paper stage:

•“Walk This Way: Estimating Impacts of Walk in Centres at Hospital Emergency Departments in the English National Health Service”, SERC Discussion Paper 167, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0167.pdf.

• “Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service”, CEP Discussion Paper 1125,

http://cep.lse.ac.uk/pubs/download/dp1125.pdf.

The following papers are under review for academic journal publication:

•“Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” (for slides see: http://www.slideshare.net/OHENews/do-financial-incentives-trump-clinical-guidance-apr15).

• “Measuring and Forecasting Hospital Quality”.

Dissemination of draft project outputs

This is a non-exhaustive list of the formal and informal methods by which the Research Team has disseminated their draft project outputs to policymakers, policy analysts and clinicians.

Since 2013, draft outputs of the research projects have been disseminated directly to policymakers in the following ways:

• Seminar presentation to Department of Health, July 2015.

• Seminar presentation to Office of Health Economics, May 2015 (attended by representatives from Monitor and Department of Health).

• Presentation of research to Department of Health group, March 2015.

• Multiple meetings to report draft project outputs to representatives of Monitor and Department of Health.

In addition, the draft project outputs have been presented to the following fora that have been attended by policymakers and policy analysts:

• Health Economics Study Group (January 2015 and June 2016).

• Royal Economics Society Meeting (March 2015).

• LSE Spatial Economics Research Centre Conference (March 2015).

• LSE STICERD Work in Progress Seminar (October 2013) (attended by representatives of Royal College of Surgeons).

• Informal workshop involving representatives from King’s Fund, and former Prime Ministerial advisors and heads of regulatory bodies (June 2015).

• Joint LSE-Dartmouth College workshop on Medical Practice Variations (September 2014).

• LSE International Health Policy Conference 2017.

Finally, the research outputs have been reported in media sources widely read by health policymakers and thought leaders, including (this is a very incomplete list) the Health Services Journal, The Guardian, The New Statesman, The Daily Telegraph, and The Financial Times.

Update October 2017:

New Work in Progress

•“The relationship between new technologies and workforce in English hospitals”, October.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”, April.

• “Patients’ choice and hospital quality competition: Unintended impacts of the signals”, October.

• “Coordinating Hospital Discharges: Bed Blocking in England”, October.

New Working Papers:

• “Taking Care of the Budget? Practice-level Outcomes during Commissioning Reforms in England”, SERC Discussion Paper 192, February, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0192.pdf.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service” CEP Discussion Paper 1434, June, http://cep.lse.ac.uk/pubs/download/dp1434.pdf.

• “The Hospital as a Multi-Product Firm: The Effect of Hospital Competition on Value-Added Indicators of Clinical Quality” CEP Discussion Paper 1484, May, http://cep.lse.ac.uk/pubs/download/dp1484.pdf.

New academic journal publications:

• “Coordinating Hospital Discharges: Bed Blocking in England”, Journal of Health Economics, accepted subject to revisions.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service”, Journal of Public Economics, accepted subject to revisions

•“Measuring and forecasting quality in English hospitals”, Journal of the Royal Statistical Society: Series A 180(2), February, pp.409-432, ISSN 0964-1998.

•“Do financial incentives trump clinical guidance? Hip replacement in England and Scotland”, Journal of Health Economics 44, pp.25-36, ISSN 0167-6296.

Since 2015, LSE have disseminated their research to individual contacts in NHS Improvement, Department of Health, the Department of Health's Economics of Social and Health Care Research Unit, the Competition and Markets Authority, and the Health Foundation.

In 2015, LSE presented their research on the tension between financial incentives and clinical guidance to a UK Government Department of Health Seminar.

In September 2015, LSE presented their research on the impacts of hospital competition to the Wennberg International Collaborative on unwarranted variations in health care utilisation and outcomes. This high-level forum included representatives from Monitor/ NHS Improvement, NHS England, and NHS Scotland, as well as senior representatives from other health care systems around the world.

In November 2016, LSE presented their research on the impact of new medical technologies within the NHS to the Health Foundation. This was a stepping stone to disseminating this research more widely to policymakers and the broader health policy community.

In May 2017, at the invitation of the UK Competition and Markets Authority (CMA), LSE presented their research on the impacts of hospital competition to an international conference of European competition regulators. The research team's findings have a direct impact on the decision-making process of competition regulators such as the CMA concerning hospital mergers. The LSE presented its findings to representatives of the following organisations:

• From the UK: the Competition and Markets Authority and NHS Improvement.

• From the Netherlands: the Authority for Competition and Markets, the Dutch Healthcare Authority, and the Ministry of Health.

• From Norway: the Competition Authority.

• From Germany: Bundeskartellamt (Federal Cartel Office).

• From France: Autorité de la concurrence (Competition Authority).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reforms and environmental shocks with health and social care outcomes.

Update November 2022:

New work in progress, not yet published:

• “Volume-outcome relationship in critically ill patients in the UK”, March 2021

• “Comparing the dangers of a hospital stay at public and private hospitals in England”, August 2021

• “Comparing health inequalities leading up to and during the first wave of Covid pandemic in England and Canada”, June 2022

• “Understanding the trajectory of frailty across the life course”, June 2022.

• “The impact of workforce turnover and temporary staff on productivity and health outcomes in the hospital sector”, September 2022

New working papers:

• “Exploring the Impact of New Medical Technology on Workforce Planning”, 2019

https://openaccess.city.ac.uk/id/eprint/22243/

• “Does choice and competition in Public Services Improve the Performance of Non-Altruistic Providers, but Worsen the Performance of Altruistic Providers?”, 2019 https://personal.lse.ac.uk/skellern/Research_files/Altruism_Competition.pdf

• “The Effect of Hospital Competition on Value-Added Indicators of Elective Surgery Quality”, 2019

http://personal.lse.ac.uk/skellern/Research_files/PROMs_comp_paper.pdf

New academic journal publications:

• “Hospital coordination and integration with social care in England: The effect on post-operative length of stay”, published in Journal of Health Economics, 2018. https://doi.org/10.1016/j.jhealeco.2018.02.005

• “Convenient primary care and emergency hospital utilisation”, published in Journal of Health Economics 2019. https://doi.org/10.1016/j.jhealeco.2019.102242

• “Impact of austerity on opioid abuse in England”, published in Social Science and Medicine, 2021 https://doi.org/10.1016/j.socscimed.2021.114511

• “Comparing the dangers of a day in English and German hospitals for high-need patients”, published in Health Services Research, 2021 https://doi.org/10.1111/1475-6773.13712

• “The diffusion of robotic surgery: Examining technology use in the English NHS”, published in the Journal of Health Policy, 2022 https://doi.org/10.1016/j.healthpol.2022.02.007

The main outcome of the presentation at the Wennberg International Collaborative was simply to raise awareness about the research findings amongst policymakers and practitioners.

Earlier work compiled by the research team (Cooper et al 2011) was cited by the then Prime Minister in support of the Health and Social Care Act 2012, which expanded choice and competition within the NHS. The research also helped to ensure that these reforms did not introduce price competition between health care providers, as had initially been proposed. The work on hospital quality and on choice and competition has been used by NHS Monitor (now NHS Improvement) in their measurement and analysis of hospital efficiency measurement, which forms one strand of their work to identify inefficient hospital trusts. The project lead has since worked with NHS Improvement to aid this strand of their work, and the work in this area also led to him becoming an adviser to the UK Competition and Markets Authority investigation into the Private Health Care Market which led to a range of measures being implemented in 2014 (see https://www.gov.uk/cma-cases/private-healthcare-market-investigation).

October 2020~:

The London School of Economics have continued working on patient choice models, competition and productivity with and increasing share of work moving to productivity as the policy perspective within the NHS changes. Below are a list of recent deliverables coming from the use of data received under DARS-NIC-354497.

Listed below are the outputs delivered since the last DSA update in mid 2019.

1) ROBOTS

a) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). How robots diffuse: a description of technology use in the English NHS. (submitted to SS&M)

b) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). The Creep of the Robots. (to be submitted soon).

Prize for the best paper ("The creep of the robots") presented at the Spanish Health Economics Association Meeting, University of Castilla la Mancha, Albacete (2019) by a young researcher. Funded by "Cátedra CaixaBank-Fedea".

Presented at:

- Department of Applied Economics, Universitat Autónoma de Barcelona (UAB), Spain, 28th May 2020.

- NHS Improvement - Economics Community Seminar, NHS England, 21st May 2020.

- Department of Health Policy Seminars, LSE, London. January 2020.

- Department of Economics, Universitat de Barcelona (UB), Spain, 6th November 2019.

- UK Health Economists Study Group (HESG) Meeting, University of East Anglia, UK, 26th-28th June 2019.

- Spanish Health Economics Association Meeting, Universidad de Castilla la Mancha, Albacete, Spain, 11th-14th June 2019.

- VIII Taller EvaluAES, University of Illes Balears, Spain, 2nd May 2019.

2) PTCA/CABG

Maynou, L; McGuire, A; Serra-Sastre, V. (2020). Exploring the impact of new medical technology on workforce planning. (to be submitted soon).

Working paper version – City, University of London, 2019:

https://openaccess.city.ac.uk/id/eprint/22243/1/Dept_Econ_WP1907%20%28002%29.pdf

Update December 2022:

The updates on further papers and their presentations since the last submission are described above in the Outputs section previously.

LSE researchers presented their work on the impact of new technology on workforce planning to NHS England and NHS Improvement in April 2019. The work had previously been discussed at several health economic conferences and research institutes. This work is beginning to be recognised as a fundamental contribution to understanding the impact of technology dissemination on the NHS workforce. It has pioneered the estimation of labour substitutability or complementarity within the NHS as new technology is taken up. It has fed in to the Health Foundation initiative, based around the Department of Public Health at the University of Cambridge, where a workshop was run that included a large number of NHS managers concerning technology uptake and labour substitutability. In this way it has helped to disseminate best practice concerning technology uptake within the NHS.

Continuing these discussions with NHS England on new technologies, the work on technology diffusion (“creep of the robots”) was discussed with NHS Improvement/NHS England at their Economics Community Seminar on 21 May 2020. The work has previously been discussed and results shared at various health policy conferences.

The work on “convenient primary care and emergency hospital utilisation” was presented to NHS England in July 2019, the results having been discussed previously with various NHS commissioners. The piece was discussed in the HSJ that year.

The working paper on the effect of competition on altruistic and non-altruistic providers was discussed member of government Behavioural Insights Team, focusing on its implications for market-based public sector reforms. In July 2018, LSE researchers met with members of NHS Improvement Economics Team, focusing on how the paper's measures of management altruism/ intrinsic motivation related to aspects of trust performance/ behaviour measured by regulators (NHS Improvement and Care Quality Commission). This and the above programmes of work are included to demonstrate our ongoing engagement with policymakers, particularly at NHS England, but as they are relatively recent presentations, we are not yet able to report yielded benefits.

The London School of Economics (LSE) research team comprises researchers from three research centres: LSE Health, Care Policy & Evaluation Centre (CPEC), and the LSE Research Laboratory (RLAB). The legal entity that LSE Health belongs to is London School of Economics, as LSE Health is a multidisciplinary research centre in advancing global research in health policy and health economics, based within the University. The research team will use HES (Hospital Episode Statistics) and PROMs (Patient Related Outcome Measures) and Civil Registration Data to make four distinct contributions to health and social care within a single programme of research. The first contribution is to analyse the impact that various aspects of policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. The second contribution compares health care system performance in several countries with the aim of spreading best practice across different countries, with specific focus on lessons that can be learnt for health and social care policy within the NHS. The third contribution develops and tests a range of multi-dimensional indicators of health care quality and outcomes. The fourth contribution analyses the link between population-level exposures to environmental shocks and health outcomes.

The purpose of receiving the data is to analyse the impact of on-going NHS reforms implemented between 2000 and the present day using pseudonymised non-sensitive patient-level data (further details of these reforms are provided below). These reforms were primarily associated with the introduction of two Acts of Parliament (the National Health Service Act 2006 and the Health and Social Care Act 2012) that changed both the organisational and payment structures of the NHS. The second Act of Parliament relies on on-going productivity gains to maintain efficient NHS output. The objective of the research programme is to assess the change in policy direction arising from these reforms, to better understand the impact of these reforms on patient outcomes and to improve the measurement of the impact of these reforms and to aid the efficiency with which they are implemented.

London School of Economics requires access to an extract of Civil Registration mortality data because a key focus of the research is the effect of NHS reforms since 2000 on health care quality. LSE have produced many outputs that use mortality as an indicator of health care quality, but have hitherto been limited to examining in-hospital mortality rather than all-location mortality because of no previous access to linked mortality data. The fact that LSE only have data on deaths in hospital has introduced a small but significant source of potential bias to previous work focusing on mortality. For instance, if some hospitals discharge patients earlier than others, then they might appear to offer higher care quality as captured by lower in-hospital mortality rates, when in fact patients from these hospitals are simply dying at home rather than in hospital. While previous work (see e.g. Cooper et al. 2011, Economic Journal) has carefully discussed this potential source of bias to show that it is unlikely to drive the findings, a more comprehensive solution to this problem is to obtain data on all-location mortality. Linking Civil Registration data to HES will enable LSE to henceforth use all-location mortality as an indicator of care quality. This will improve the quality of research, and improve the ability of policymakers to confidently formulate policy changes aimed at improving health and social care that is informed by the findings of the research.

Research deliverables are currently underway to examine the impact of the following reforms to the NHS and include the following:

* Introduction of Payment by Results (2003-2006).

* Implementation of waiting time targets for first outpatient appointment, elective surgery, and A&E attendances (2001-2005).

* Introduction of the Quality and Outcomes Framework (2004).

* Introduction of patient choice of hospital and GP surgery (2006-2008).

* Introduction of independent care providers, both as part of the Independent Sector Treatment Centre programme and under the Any Qualified Provider programme (2003-2010).

* Introduction of Walk in Centres for ambulatory care (2000-2010).

* Introduction of the Alternative Provider of Medical Services GP contract (2004).

* Expansion of primary care provision under the Equitable Access to Primary Care initiative (2007-2010).

* Introduction of Clinical Commissioning Groups in place of Primary Care Trusts (2013-2014).

* Progress towards the Nicholson productivity challenge (2009-2015).

* Introduction of new signals of hospital outcomes and performance, including the NHS Choices website (2006), Patient Reported Outcome Measures (2009), the NHS Staff Survey (2003), and various NHS Patient Satisfaction and Patient Experience surveys.

Each of these research deliverables form part of the first contribution to health and social care outlined above, by analysing a specific policy introduced within the NHS over the last 15 years. Each of these deliverables also forms part of the third contribution to health and social care, in that each focuses on analysing the impact of a particular policy or reform on one or more multi-dimensional indicators of health care quality and outcomes.

The research team has primarily progressed the second contribution to health and social care – a cross-country comparison of health care system performance – via a project entitled “Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” that examines the impact of financial incentives on clinicians’ decisions in England and Scotland. Making further progress toward this second contribution to health and social care will be a major focus of the research programme over the next 2-3 years.

The research team intends to progress the fourth contribution to health and social care – analysing health responses to population-level exposures to environmental shocks such as pollution. A key aim of this fourth contribution is to estimate the causal relationship between ambient air pollution and hospital admissions. Another objective of this fourth contribution is to evaluate the health impact of the London Congestion Charge via changes in air quality in the London area. Specifically, the research team intend to investigate whether the introduction of the Congestion Charge and the subsequent change in air quality in London decreased the frequency and duration of hospital admissions for pollution-related diseases, particularly among sensitive groups such as infants and the elderly.

Using patient-level data is necessary for risk adjustment at the patient level, thereby allowing control of confounding factors that will affect the analysis. Using patient-level data is also necessary to construct various inputs into the analysis -- for example, percentiles of distance from patient's GP surgery to hospital of admission, which are needed to construct indices that define hospital referral markets and potential areas of competition. All programme outputs that have used data NHS Digital has provided have been aggregated with small number suppression in line with the HES analysis guide.

A significant portion of the research programme involves assessment of NHS reforms initiated during the first decade of the 2000s. To effectively assess these reforms, not only is data from these years required, but also, data from the pre-reform period is required, in order to establish a baseline against which subsequent health care provider behaviour and performance can be compared. For this reason, it is crucial to have data from 1996/1997 onwards.

Another core focus of the research programme is to assess efforts to increase NHS productivity in the years since 2010. These efforts were initially linked to the ’Nicholson challenge’ to find £20 billion in efficiency savings by 2015, but have continued since then in light of continued pressures on NHS funding. In order to pursue this aspect of our research programme, data from 2009/10 to the present are required.

A large number of the outputs produced as part of this research programme examine mortality as an outcome variable. HES provides data in deaths in hospital, but it does not provide data on deaths subsequent to discharge. Studies that examine mortality using only HES always face questions about the potential that their results are biased by the exclusive focus on in-hospital deaths, as the pattern of all-location mortality may be different to the pattern of in-hospital mortality. Linking HES data to mortality data will provide this research team with a comprehensive means of eliminating this potential source of bias, by allowing them to analyse all-location mortality rather than in-hospital mortality.

The request for data primarily pertains to the first purpose (analysing the impact of various aspects of policy-development and reform of the NHS), in the manner described below. Access to more recent years of data will also enable LSE to further the fourth purpose (analysing the link between population-level exposures to environmental shocks and health outcomes) by enabling this analysis to be conducted using up-to-date data.

The first purpose is designed to inform current policy requirements. The more contemporaneous the data is, the better LSE can achieve this objective. The most recent years have also seen the greatest financial constraints, even accounting for some uplift payments, and the research team are most interested in documenting how the NHS has coped under this financial stringency. Below LSE outline three key areas where access to new years of data will be of particular value.

One policy implication of tightening budgets is in the interface between NHS hospital performance and the community care provided by Local Authorities. One strand of the on-going research on productivity, which will continue under a renewed grant from the DHSC to the LSE (and LSE have already presented some early results of this work to the DHSC), is concerned with how hospital discharge decisions are affected by the supply constraints faced by Local Authorities with regards to the provision of community care services. If there is insufficient supply of care in the community then, regardless of the efficiency gains achieved by hospitals in their discharge processes, bed-blocking will still occur. LSE require up-to-date HES data to document how these relationships have evolved under recent changes to NHS finances. LSE's aim is that this research will identify how the NHS and Local Authorities can coordinate care provision more effectively, thus contributing to improved hospital performance and more joined-up care.

A second strand of the first research purpose is examining patient choice as a means of delivering high quality health care within the NHS, as is articulated in the NHS Constitution. In particular, LSE are empirically analysing how patients and their GPs make elective surgery referral choices, and what specific signals of provider quality they react to. The research team know and can already document that waiting time for elective surgery has a major impact on choice of hospital. Over the past few years, waiting time targets have been missed by many providers. LSE will supplement existing work on patient choice to investigate how these missed targets have affected patient choice. LSE are particularly interested in assessing whether access to care for individuals in the most deprived areas has been more adversely affected by worsening targets, and whether there has been a measurable impact on health outcomes as a consequence. Access to data for more recent years, when achievement of waiting time targets has worsened considerably, is necessary to undertake this investigation.

A third strand of investigation necessitating up-to-date data relates to interest in productivity through an analysis of the up-take and diffusion of new health care technologies. In particular, LSE are examining how new technology either substitutes or complements existing technology. As referenced by the UK Office for Budget Responsibility (Fiscal Sustainability and Public Health Spending, September 2016), earlier work by LSE using HES data on two common surgical procedures (angioplasty and coronary artery bypass grafting) has shown that technological innovations are generally cost-escalating rather than cost-containing. LSE are in the process of extending this work to consider implications for labour input choices — both substitution between labour and capital, and substitution between different types of labour (physician specialities). LSE require access to new data to examine the diffusion of new health care technologies since 2014/15.

An aspect of this work is funded by The Health Foundation. The Health Foundation work is contributing to the first research purpose which is on the impact that policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. LSE are linking the up-take of new technology as guided by policy-development and assessing the impact that it has on new surgical procedures, patient outcomes and provider behaviour. Specifically LSE are considering the regulatory support for new surgical procedures as these new procedures will affect patient outcomes and provider behaviour, in this specific case the impact will be on provider workforce composition.

LSE have taken surgical procedures and related this to the impact on the NHS workforce by considering whether the surgical composition has changed as a result of the policy support, through NHS and NICE guidance, for new surgical techniques. For example, LSE are currently looking at the impact on provider behaviour, in terms of workforce composition, as Percutaneous Transluminal Coronary Angioplasty (PTCA) has replaced Coronary Artery Bypass Grafting (CABG).

The London School of Economics relies on GDPR Article 6 (1) (e), to carry out its public task and for processing special categories of data (including health information); GDPR Article 9.2(j), for archiving, research and statistics, as the study is a research project which will use data and statistics, in accordance with Article 89(1).

The expected outputs consist of research reports and published papers, and discussions and presentations to UK health and social care policymakers, policy analysts, and clinicians. A list of outputs to date is provided below. The primary target audience for these outputs is the health policy community. This includes policymakers, as a key aim of the research is to investigate the impact of recent changes to health and social care policy, with an ultimate objective of influencing future policy formation. However, it also includes other policy analysts, such as (but not limited to) those at the Health Foundation, the King’s Fund and Nuffield Trust, who, while they may not be directly involved in the policy formation process, do have an important influence over the terms under which health policy is debated and therefore formulated.

A secondary target audience is the medical community that has been responsible for implementing many of the policy reforms analysed, and whose decisions therefore determine the success of these reforms, and the nature of their impacts.

Another secondary target audience for the team's fourth contribution, on the link between population-level exposures to environmental shocks and health outcomes, is environmental policymakers -- for example those responsible for air pollution regulations. This fourth contribution aims to benefit health and social care by providing more rigorous evidence than is currently available concerning the effects on population health of environmental policies such as the London Congestion charge and the T-charge (emissions surcharge).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reform and health and social care outcomes. A few of these variables (e.g. whether a patient is discharged as dead) appear directly in HES, but most (e.g. length of hospital stay, patient severity aggregating across multiple diagnoses, hospital productivity, or intensity of competition to which a hospital is exposed) are constructed using multiple underlying HES variables. HES data will only feature directly in the outputs of these research projects in tables of summary statistics that report properties of key variables used in the analysis (such as minimum, maximum and average values).

No data or datasets using HES data will be published or made available, either at the individual patient level or at an aggregate level, as part of this programme of work. The data will not be used for any commercial purpose.

LSE hope to improve all such research by using the civil registration data to henceforth examine all-location mortality rather than in-hospital mortality.

A key part of the research programme is to assess the impact of the Health and Social Care Act 2012, and interrelated reforms. Examples of changes associated with this legislation that are being assessed include:

• 2012 introduction of Any Qualified Provider.

• 2013 introduction of Clinical Commissioning Groups.

• 2015 introduction of patient choice of General Practitioner.

• Phases 1 and 2 of the Quality, Innovation, Productivity and Prevention (QIPP).

• Effects of NHS contracting reforms on the relationship between hospital trusts and Local Authorities, with a particular focus on effects on bed blocking.

To assess these reforms, the research team require years of data from after their implementation. Many changes resulting from this legislation did not take effect until April 2013 and their full impact was not felt until some time after that. Obtaining data up to 2018/2019 will enable a comprehensive assessment of the impact of these reforms over time.

Several project outputs are already available in draft form, and are expected to be published in final form over the next 3 years.

Draft project outputs already produced

In this field of work, the life cycle of a research project can be roughly summarised as follows: work in progress presentation (slides only); unpublished mimeo; Working Paper (which may also be a final output, or may be progressed to academic journal submission); submission to academic journal (if relevant); and publication of final report or journal article. Irrespective of the final publication location, the research team takes substantial effort to disseminate its outputs by presenting findings to policymakers and policy analysts.

The following research projects are at work in progress stage:

•“Taking care of the budget? Clinical decisions and Patient Outcomes under recent NHS reforms”.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”.

• “Home for the Holidays: Evidence on the Relationship Between Prospective Payment, Length of Stay, and Patient Outcomes”.

The following research projects are at mimeo stage

•“The hospital as a multi-product firm: Measuring the effect of hospital competition on quality using Patient-Reported Outcome Measures”.

• “Independent Sector Treatment Centres in the English NHS: Effects on neighbouring NHS hospitals”.

The following research projects are at Working Paper stage:

•“Walk This Way: Estimating Impacts of Walk in Centres at Hospital Emergency Departments in the English National Health Service”, SERC Discussion Paper 167, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0167.pdf.

• “Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service”, CEP Discussion Paper 1125,

http://cep.lse.ac.uk/pubs/download/dp1125.pdf.

The following papers are under review for academic journal publication:

•“Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” (for slides see: http://www.slideshare.net/OHENews/do-financial-incentives-trump-clinical-guidance-apr15).

• “Measuring and Forecasting Hospital Quality”.

Dissemination of draft project outputs

This is a non-exhaustive list of the formal and informal methods by which the Research Team has disseminated their draft project outputs to policymakers, policy analysts and clinicians.

Since 2013, draft outputs of the research projects have been disseminated directly to policymakers in the following ways:

• Seminar presentation to Department of Health, July 2015.

• Seminar presentation to Office of Health Economics, May 2015 (attended by representatives from Monitor and Department of Health).

• Presentation of research to Department of Health group, March 2015.

• Multiple meetings to report draft project outputs to representatives of Monitor and Department of Health.

In addition, the draft project outputs have been presented to the following fora that have been attended by policymakers and policy analysts:

• Health Economics Study Group (January 2015 and June 2016).

• Royal Economics Society Meeting (March 2015).

• LSE Spatial Economics Research Centre Conference (March 2015).

• LSE STICERD Work in Progress Seminar (October 2013) (attended by representatives of Royal College of Surgeons).

• Informal workshop involving representatives from King’s Fund, and former Prime Ministerial advisors and heads of regulatory bodies (June 2015).

• Joint LSE-Dartmouth College workshop on Medical Practice Variations (September 2014).

• LSE International Health Policy Conference 2017.

Finally, the research outputs have been reported in media sources widely read by health policymakers and thought leaders, including (this is a very incomplete list) the Health Services Journal, The Guardian, The New Statesman, The Daily Telegraph, and The Financial Times.

Update October 2017:

New Work in Progress

•“The relationship between new technologies and workforce in English hospitals”, October.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”, April.

• “Patients’ choice and hospital quality competition: Unintended impacts of the signals”, October.

• “Coordinating Hospital Discharges: Bed Blocking in England”, October.

New Working Papers:

• “Taking Care of the Budget? Practice-level Outcomes during Commissioning Reforms in England”, SERC Discussion Paper 192, February, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0192.pdf.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service” CEP Discussion Paper 1434, June, http://cep.lse.ac.uk/pubs/download/dp1434.pdf.

• “The Hospital as a Multi-Product Firm: The Effect of Hospital Competition on Value-Added Indicators of Clinical Quality” CEP Discussion Paper 1484, May, http://cep.lse.ac.uk/pubs/download/dp1484.pdf.

New academic journal publications:

• “Coordinating Hospital Discharges: Bed Blocking in England”, Journal of Health Economics, accepted subject to revisions.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service”, Journal of Public Economics, accepted subject to revisions

•“Measuring and forecasting quality in English hospitals”, Journal of the Royal Statistical Society: Series A 180(2), February, pp.409-432, ISSN 0964-1998.

•“Do financial incentives trump clinical guidance? Hip replacement in England and Scotland”, Journal of Health Economics 44, pp.25-36, ISSN 0167-6296.

Since 2015, LSE have disseminated their research to individual contacts in NHS Improvement, Department of Health, the Department of Health's Economics of Social and Health Care Research Unit, the Competition and Markets Authority, and the Health Foundation.

In 2015, LSE presented their research on the tension between financial incentives and clinical guidance to a UK Government Department of Health Seminar.

In September 2015, LSE presented their research on the impacts of hospital competition to the Wennberg International Collaborative on unwarranted variations in health care utilisation and outcomes. This high-level forum included representatives from Monitor/ NHS Improvement, NHS England, and NHS Scotland, as well as senior representatives from other health care systems around the world.

In November 2016, LSE presented their research on the impact of new medical technologies within the NHS to the Health Foundation. This was a stepping stone to disseminating this research more widely to policymakers and the broader health policy community. This work is beginning to be recognised as a fundamental contribution to understanding the impact of technology dissemination on the NHS workforce. It has pioneered the estimation of labour substitutability or complementarity within the NHS as new technology is taken up. It has fed in to the Health Foundation initiative, based around the Department of Public Health at the University of Cambridge, where a workshop was run that included a large number of NHS managers concerning technology uptake and labour substitutability. In this way it has helped to disseminate best practice concerning technology uptake within the NHS

In May 2017, at the invitation of the UK Competition and Markets Authority (CMA), LSE presented their research on the impacts of hospital competition to an international conference of European competition regulators. The research team's findings have a direct impact on the decision-making process of competition regulators such as the CMA concerning hospital mergers. The LSE presented its findings to representatives of the following organisations:

• From the UK: the Competition and Markets Authority and NHS Improvement.

• From the Netherlands: the Authority for Competition and Markets, the Dutch Healthcare Authority, and the Ministry of Health.

• From Norway: the Competition Authority.

• From Germany: Bundeskartellamt (Federal Cartel Office).

• From France: Autorité de la concurrence (Competition Authority).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reforms and environmental shocks with health and social care outcomes.

The main outcome of the presentation at the Wennberg International Collaborative was simply to raise awareness about the research findings amongst policymakers and practitioners.

Earlier work compiled by the research team (Cooper et al 2011) was cited by the then Prime Minister in support of the Health and Social Care Act 2012, which expanded choice and competition within the NHS. The research also helped to ensure that these reforms did not introduce price competition between health care providers, as had initially been proposed. The work on hospital quality and on choice and competition has been used by NHS Monitor (now NHS Improvement) in their measurement and analysis of hospital efficiency measurement, which forms one strand of their work to identify inefficient hospital trusts. The project lead has since worked with NHS Improvement to aid this strand of their work, and the work in this area also led to him becoming an adviser to the UK Competition and Markets Authority investigation into the Private Health Care Market which led to a range of measures being implemented in 2014 (see https://www.gov.uk/cma-cases/private-healthcare-market-investigation).

October 2020~:

The London School of Economics have continued working on patient choice models, competition and productivity with and increasing share of work moving to productivity as the policy perspective within the NHS changes. Below are a list of recent deliverables coming from the use of data received under DARS-NIC-354497.

Listed below are the outputs delivered since the last DSA update in mid 2019.

1) ROBOTS

a) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). How robots diffuse: a description of technology use in the English NHS. (submitted to SS&M)

b) Maynou, L; Troutman, G; McGuire, A and Serra-Sastre, V. (2020). The Creep of the Robots. (to be submitted soon).

Prize for the best paper ("The creep of the robots") presented at the Spanish Health Economics Association Meeting, University of Castilla la Mancha, Albacete (2019) by a young researcher. Funded by "Cátedra CaixaBank-Fedea".

Presented at:

- Department of Applied Economics, Universitat Autónoma de Barcelona (UAB), Spain, 28th May 2020.

- NHS Improvement - Economics Community Seminar, NHS England, 21st May 2020.

- Department of Health Policy Seminars, LSE, London. January 2020.

- Department of Economics, Universitat de Barcelona (UB), Spain, 6th November 2019.

- UK Health Economists Study Group (HESG) Meeting, University of East Anglia, UK, 26th-28th June 2019.

- Spanish Health Economics Association Meeting, Universidad de Castilla la Mancha, Albacete, Spain, 11th-14th June 2019.

- VIII Taller EvaluAES, University of Illes Balears, Spain, 2nd May 2019.

2) PTCA/CABG

Maynou, L; McGuire, A; Serra-Sastre, V. (2020). Exploring the impact of new medical technology on workforce planning. (to be submitted soon).

Working paper version – City, University of London, 2019:

https://openaccess.city.ac.uk/id/eprint/22243/1/Dept_Econ_WP1907%20%28002%29.pdf

The London School of Economics (LSE) research team comprises researchers from three research centres: LSE Health, Care Policy & Evaluation Centre (CPEC), and the LSE Research Laboratory (RLAB). The legal entity that LSE Health belongs to is London School of Economics, as LSE Health is a multidisciplinary research centre in advancing global research in health policy and health economics, based within the University. The research team will use HES (Hospital Episode Statistics) and PROMs (Patient Related Outcome Measures) and Civil Registration Data to make four distinct contributions to health and social care within a single programme of research. The first contribution is to analyse the impact that various aspects of policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. The second contribution compares health care system performance in several countries with the aim of spreading best practice across different countries, with specific focus on lessons that can be learnt for health and social care policy within the NHS. The third contribution develops and tests a range of multi-dimensional indicators of health care quality and outcomes. The fourth contribution analyses the link between population-level exposures to environmental shocks and health outcomes.

The purpose of receiving the data is to analyse the impact of on-going NHS reforms implemented between 2000 and the present day using pseudonymised non-sensitive patient-level data (further details of these reforms are provided below). These reforms were primarily associated with the introduction of two Acts of Parliament (the National Health Service Act 2006 and the Health and Social Care Act 2012) that changed both the organisational and payment structures of the NHS. The second Act of Parliament relies on on-going productivity gains to maintain efficient NHS output. The objective of the research programme is to assess the change in policy direction arising from these reforms, to better understand the impact of these reforms on patient outcomes and to improve the measurement of the impact of these reforms and to aid the efficiency with which they are implemented.

London School of Economics requires access to an extract of Civil Registration mortality data because a key focus of the research is the effect of NHS reforms since 2000 on health care quality. LSE have produced many outputs that use mortality as an indicator of health care quality, but have hitherto been limited to examining in-hospital mortality rather than all-location mortality because of no previous access to linked mortality data. The fact that LSE only have data on deaths in hospital has introduced a small but significant source of potential bias to previous work focusing on mortality. For instance, if some hospitals discharge patients earlier than others, then they might appear to offer higher care quality as captured by lower in-hospital mortality rates, when in fact patients from these hospitals are simply dying at home rather than in hospital. While previous work (see e.g. Cooper et al. 2011, Economic Journal) has carefully discussed this potential source of bias to show that it is unlikely to drive the findings, a more comprehensive solution to this problem is to obtain data on all-location mortality. Linking Civil Registration data to HES will enable LSE to henceforth use all-location mortality as an indicator of care quality. This will improve the quality of research, and improve the ability of policymakers to confidently formulate policy changes aimed at improving health and social care that is informed by the findings of the research.

Research deliverables are currently underway to examine the impact of the following reforms to the NHS and include the following:

* Introduction of Payment by Results (2003-2006).

* Implementation of waiting time targets for first outpatient appointment, elective surgery, and A&E attendances (2001-2005).

* Introduction of the Quality and Outcomes Framework (2004).

* Introduction of patient choice of hospital and GP surgery (2006-2008).

* Introduction of independent care providers, both as part of the Independent Sector Treatment Centre programme and under the Any Qualified Provider programme (2003-2010).

* Introduction of Walk in Centres for ambulatory care (2000-2010).

* Introduction of the Alternative Provider of Medical Services GP contract (2004).

* Expansion of primary care provision under the Equitable Access to Primary Care initiative (2007-2010).

* Introduction of Clinical Commissioning Groups in place of Primary Care Trusts (2013-2014).

* Progress towards the Nicholson productivity challenge (2009-2015).

* Introduction of new signals of hospital outcomes and performance, including the NHS Choices website (2006), Patient Reported Outcome Measures (2009), the NHS Staff Survey (2003), and various NHS Patient Satisfaction and Patient Experience surveys.

Each of these research deliverables form part of the first contribution to health and social care outlined above, by analysing a specific policy introduced within the NHS over the last 15 years. Each of these deliverables also forms part of the third contribution to health and social care, in that each focuses on analysing the impact of a particular policy or reform on one or more multi-dimensional indicators of health care quality and outcomes.

The research team has primarily progressed the second contribution to health and social care – a cross-country comparison of health care system performance – via a project entitled “Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” that examines the impact of financial incentives on clinicians’ decisions in England and Scotland. Making further progress toward this second contribution to health and social care will be a major focus of the research programme over the next 2-3 years.

The research team intends to progress the fourth contribution to health and social care – analysing health responses to population-level exposures to environmental shocks such as pollution. A key aim of this fourth contribution is to estimate the causal relationship between ambient air pollution and hospital admissions. Another objective of this fourth contribution is to evaluate the health impact of the London Congestion Charge via changes in air quality in the London area. Specifically, the research team intend to investigate whether the introduction of the Congestion Charge and the subsequent change in air quality in London decreased the frequency and duration of hospital admissions for pollution-related diseases, particularly among sensitive groups such as infants and the elderly.

Using patient-level data is necessary for risk adjustment at the patient level, thereby allowing control of confounding factors that will affect the analysis. Using patient-level data is also necessary to construct various inputs into the analysis -- for example, percentiles of distance from patient's GP surgery to hospital of admission, which are needed to construct indices that define hospital referral markets and potential areas of competition. All programme outputs that have used data NHS Digital has provided have been aggregated with small number suppression in line with the HES analysis guide.

A significant portion of the research programme involves assessment of NHS reforms initiated during the first decade of the 2000s. To effectively assess these reforms, not only is data from these years required, but also, data from the pre-reform period is required, in order to establish a baseline against which subsequent health care provider behaviour and performance can be compared. For this reason, it is crucial to have data from 1996/1997 onwards.

Another core focus of the research programme is to assess efforts to increase NHS productivity in the years since 2010. These efforts were initially linked to the ’Nicholson challenge’ to find £20 billion in efficiency savings by 2015, but have continued since then in light of continued pressures on NHS funding. In order to pursue this aspect of our research programme, data from 2009/10 to the present are required.

A large number of the outputs produced as part of this research programme examine mortality as an outcome variable. HES provides data in deaths in hospital, but it does not provide data on deaths subsequent to discharge. Studies that examine mortality using only HES always face questions about the potential that their results are biased by the exclusive focus on in-hospital deaths, as the pattern of all-location mortality may be different to the pattern of in-hospital mortality. Linking HES data to mortality data will provide this research team with a comprehensive means of eliminating this potential source of bias, by allowing them to analyse all-location mortality rather than in-hospital mortality.

******

The request for additional years of data primarily pertains to the first purpose (analysing the impact of various aspects of policy-development and reform of the NHS), in the manner described below. However, access to more recent years of data will also enable LSE to further the new, fourth purpose (analysing the link between population-level exposures to environmental shocks and health outcomes) by enabling this analysis to be conducted using up-to-date data.

The first purpose is designed to inform current policy requirements. The more contemporaneous the data is, the better LSE can achieve this objective. The most recent years have also seen the greatest financial constraints, even accounting for some uplift payments, and the research team are most interested in documenting how the NHS has coped under this financial stringency. Below LSE outline three key areas where access to new years of data will be of particular value.

One policy implication of tightening budgets is in the interface between NHS hospital performance and the community care provided by Local Authorities. One strand of the on-going research on productivity, which will continue under a renewed grant from the DHSC to the LSE (and LSE have already presented some early results of this work to the DHSC), is concerned with how hospital discharge decisions are affected by the supply constraints faced by Local Authorities with regards to the provision of community care services. If there is insufficient supply of care in the community then, regardless of the efficiency gains achieved by hospitals in their discharge processes, bed-blocking will still occur. LSE require up-to-date HES data to document how these relationships have evolved under recent changes to NHS finances. LSE's aim is that this research will identify how the NHS and Local Authorities can coordinate care provision more effectively, thus contributing to improved hospital performance and more joined-up care.

A second strand of the first research purpose is examining patient choice as a means of delivering high quality health care within the NHS, as is articulated in the NHS Constitution. In particular, LSE are empirically analysing how patients and their GPs make elective surgery referral choices, and what specific signals of provider quality they react to. The research team know and can already document that waiting time for elective surgery has a major impact on choice of hospital. Over the past few years, waiting time targets have been missed by many providers. LSE will supplement existing work on patient choice to investigate how these missed targets have affected patient choice. LSE are particularly interested in assessing whether access to care for individuals in the most deprived areas has been more adversely affected by worsening targets, and whether there has been a measurable impact on health outcomes as a consequence. Access to data for more recent years, when achievement of waiting time targets has worsened considerably, is necessary to undertake this investigation.

A third strand of investigation necessitating up-to-date data relates to interest in productivity through an analysis of the up-take and diffusion of new health care technologies. In particular, LSE are examining how new technology either substitutes or complements existing technology. As referenced by the UK Office for Budget Responsibility (Fiscal Sustainability and Public Health Spending, September 2016), earlier work by LSE using HES data on two common surgical procedures (angioplasty and coronary artery bypass grafting) has shown that technological innovations are generally cost-escalating rather than cost-containing. LSE are in the process of extending this work to consider implications for labour input choices — both substitution between labour and capital, and substitution between different types of labour (physician specialities). LSE require access to new data to examine the diffusion of new health care technologies since 2014/15.

An aspect of this work is funded by The Health Foundation. The Health Foundation work is contributing to the first research purpose which is on the impact that policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. LSE are linking the up-take of new technology as guided by policy-development and assessing the impact that it has on new surgical procedures, patient outcomes and provider behaviour. Specifically LSE are considering the regulatory support for new surgical procedures as these new procedures will affect patient outcomes and provider behaviour, in this specific case the impact will be on provider workforce composition.

LSE have taken surgical procedures and related this to the impact on the NHS workforce by considering whether the surgical composition has changed as a result of the policy support, through NHS and NICE guidance, for new surgical techniques. For example, LSE are currently looking at the impact on provider behaviour, in terms of workforce composition, as Percutaneous Transluminal Coronary Angioplasty (PTCA) has replaced Coronary Artery Bypass Grafting (CABG).

A full re-supply of HES APC data will be given as part of v2 of this agreement - this is due to data quality issues that occurred with the last dissemination of HES APC data and the migration into the LSE system.

The expected outputs consist of research reports and published papers, and discussions and presentations to UK health and social care policymakers, policy analysts, and clinicians. A list of outputs to date is provided below. The primary target audience for these outputs is the health policy community. This includes policymakers, as a key aim of the research is to investigate the impact of recent changes to health and social care policy, with an ultimate objective of influencing future policy formation. However, it also includes other policy analysts, such as (but not limited to) those at the Health Foundation, the King’s Fund and Nuffield Trust, who, while they may not be directly involved in the policy formation process, do have an important influence over the terms under which health policy is debated and therefore formulated.

A secondary target audience is the medical community that has been responsible for implementing many of the policy reforms analysed, and whose decisions therefore determine the success of these reforms, and the nature of their impacts.

Another secondary target audience for the team's fourth contribution, on the link between population-level exposures to environmental shocks and health outcomes, is environmental policymakers -- for example those responsible for air pollution regulations. This fourth contribution aims to benefit health and social care by providing more rigorous evidence than is currently available concerning the effects on population health of environmental policies such as the London Congestion charge and the T-charge (emissions surcharge).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reform and health and social care outcomes. A few of these variables (e.g. whether a patient is discharged as dead) appear directly in HES, but most (e.g. length of hospital stay, patient severity aggregating across multiple diagnoses, hospital productivity, or intensity of competition to which a hospital is exposed) are constructed using multiple underlying HES variables. HES data will only feature directly in the outputs of these research projects in tables of summary statistics that report properties of key variables used in the analysis (such as minimum, maximum and average values).

No data or datasets using HES data will be published or made available, either at the individual patient level or at an aggregate level, as part of this programme of work. The data will not be used for any commercial purpose.

LSE hope to improve all such research by using the civil registration data to henceforth examine all-location mortality rather than in-hospital mortality.

A key part of the research programme is to assess the impact of the Health and Social Care Act 2012, and interrelated reforms. Examples of changes associated with this legislation that are being assessed include:

• 2012 introduction of Any Qualified Provider.

• 2013 introduction of Clinical Commissioning Groups.

• 2015 introduction of patient choice of General Practitioner.

• Phases 1 and 2 of the Quality, Innovation, Productivity and Prevention (QIPP).

• Effects of NHS contracting reforms on the relationship between hospital trusts and Local Authorities, with a particular focus on effects on bed blocking.

To assess these reforms, the research team require years of data from after their implementation. Many changes resulting from this legislation did not take effect until April 2013 and their full impact was not felt until some time after that. Obtaining data up to 2018/2019 will enable a comprehensive assessment of the impact of these reforms over time.

Several project outputs are already available in draft form, and are expected to be published in final form over the next 3 years.

Draft project outputs already produced

In this field of work, the life cycle of a research project can be roughly summarised as follows: work in progress presentation (slides only); unpublished mimeo; Working Paper (which may also be a final output, or may be progressed to academic journal submission); submission to academic journal (if relevant); and publication of final report or journal article. Irrespective of the final publication location, the research team takes substantial effort to disseminate its outputs by presenting findings to policymakers and policy analysts.

The following research projects are at work in progress stage:

•“Taking care of the budget? Clinical decisions and Patient Outcomes under recent NHS reforms”.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”.

• “Home for the Holidays: Evidence on the Relationship Between Prospective Payment, Length of Stay, and Patient Outcomes”.

The following research projects are at mimeo stage

•“The hospital as a multi-product firm: Measuring the effect of hospital competition on quality using Patient-Reported Outcome Measures”.

• “Independent Sector Treatment Centres in the English NHS: Effects on neighbouring NHS hospitals”.

The following research projects are at Working Paper stage:

•“Walk This Way: Estimating Impacts of Walk in Centres at Hospital Emergency Departments in the English National Health Service”, SERC Discussion Paper 167, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0167.pdf.

• “Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service”, CEP Discussion Paper 1125,

http://cep.lse.ac.uk/pubs/download/dp1125.pdf.

The following papers are under review for academic journal publication:

•“Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” (for slides see: http://www.slideshare.net/OHENews/do-financial-incentives-trump-clinical-guidance-apr15).

• “Measuring and Forecasting Hospital Quality”.

Dissemination of draft project outputs

This is a non-exhaustive list of the formal and informal methods by which the Research Team has disseminated their draft project outputs to policymakers, policy analysts and clinicians.

Since 2013, draft outputs of the research projects have been disseminated directly to policymakers in the following ways:

• Seminar presentation to Department of Health, July 2015.

• Seminar presentation to Office of Health Economics, May 2015 (attended by representatives from Monitor and Department of Health).

• Presentation of research to Department of Health group, March 2015.

• Multiple meetings to report draft project outputs to representatives of Monitor and Department of Health.

In addition, the draft project outputs have been presented to the following fora that have been attended by policymakers and policy analysts:

• Health Economics Study Group (January 2015 and June 2016).

• Royal Economics Society Meeting (March 2015).

• LSE Spatial Economics Research Centre Conference (March 2015).

• LSE STICERD Work in Progress Seminar (October 2013) (attended by representatives of Royal College of Surgeons).

• Informal workshop involving representatives from King’s Fund, and former Prime Ministerial advisors and heads of regulatory bodies (June 2015).

• Joint LSE-Dartmouth College workshop on Medical Practice Variations (September 2014).

• LSE International Health Policy Conference 2017.

Finally, the research outputs have been reported in media sources widely read by health policymakers and thought leaders, including (this is a very incomplete list) the Health Services Journal, The Guardian, The New Statesman, The Daily Telegraph, and The Financial Times.

Update October 2017:

New Work in Progress

•“The relationship between new technologies and workforce in English hospitals”, October.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”, April.

• “Patients’ choice and hospital quality competition: Unintended impacts of the signals”, October.

• “Coordinating Hospital Discharges: Bed Blocking in England”, October.

New Working Papers:

• “Taking Care of the Budget? Practice-level Outcomes during Commissioning Reforms in England”, SERC Discussion Paper 192, February, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0192.pdf.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service” CEP Discussion Paper 1434, June, http://cep.lse.ac.uk/pubs/download/dp1434.pdf.

• “The Hospital as a Multi-Product Firm: The Effect of Hospital Competition on Value-Added Indicators of Clinical Quality” CEP Discussion Paper 1484, May, http://cep.lse.ac.uk/pubs/download/dp1484.pdf.

New academic journal publications:

• “Coordinating Hospital Discharges: Bed Blocking in England”, Journal of Health Economics, accepted subject to revisions.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service”, Journal of Public Economics, accepted subject to revisions

•“Measuring and forecasting quality in English hospitals”, Journal of the Royal Statistical Society: Series A 180(2), February, pp.409-432, ISSN 0964-1998.

•“Do financial incentives trump clinical guidance? Hip replacement in England and Scotland”, Journal of Health Economics 44, pp.25-36, ISSN 0167-6296.

Since 2015, LSE have disseminated their research to individual contacts in NHS Improvement, Department of Health, the Department of Health's Economics of Social and Health Care Research Unit, the Competition and Markets Authority, and the Health Foundation.

In 2015, LSE presented their research on the tension between financial incentives and clinical guidance to a UK Government Department of Health Seminar.

In September 2015, LSE presented their research on the impacts of hospital competition to the Wennberg International Collaborative on unwarranted variations in health care utilisation and outcomes. This high-level forum included representatives from Monitor/ NHS Improvement, NHS England, and NHS Scotland, as well as senior representatives from other health care systems around the world.

In November 2016, LSE presented their research on the impact of new medical technologies within the NHS to the Health Foundation. This was a stepping stone to disseminating this research more widely to policymakers and the broader health policy community. This work is beginning to be recognised as a fundamental contribution to understanding the impact of technology dissemination on the NHS workforce. It has pioneered the estimation of labour substitutability or complementarity within the NHS as new technology is taken up. It has fed in to the Health Foundation initiative, based around the Department of Public Health at the University of Cambridge, where a workshop was run that included a large number of NHS managers concerning technology uptake and labour substitutability. In this way it has helped to disseminate best practice concerning technology uptake within the NHS

In May 2017, at the invitation of the UK Competition and Markets Authority (CMA), LSE presented their research on the impacts of hospital competition to an international conference of European competition regulators. The research team's findings have a direct impact on the decision-making process of competition regulators such as the CMA concerning hospital mergers. The LSE presented its findings to representatives of the following organisations:

• From the UK: the Competition and Markets Authority and NHS Improvement.

• From the Netherlands: the Authority for Competition and Markets, the Dutch Healthcare Authority, and the Ministry of Health.

• From Norway: the Competition Authority.

• From Germany: Bundeskartellamt (Federal Cartel Office).

• From France: Autorité de la concurrence (Competition Authority).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reforms and environmental shocks with health and social care outcomes.

The main outcome of the presentation at the Wennberg International Collaborative was simply to raise awareness about the research findings amongst policymakers and practitioners.

Earlier work compiled by the research team (Cooper et al 2011) was cited by the then Prime Minister in support of the Health and Social Care Act 2012, which expanded choice and competition within the NHS. The research also helped to ensure that these reforms did not introduce price competition between health care providers, as had initially been proposed. The work on hospital quality and on choice and competition has been used by NHS Monitor (now NHS Improvement) in their measurement and analysis of hospital efficiency measurement, which forms one strand of their work to identify inefficient hospital trusts. The project lead has since worked with NHS Improvement to aid this strand of their work, and the work in this area also led to him becoming an adviser to the UK Competition and Markets Authority investigation into the Private Health Care Market which led to a range of measures being implemented in 2014 (see https://www.gov.uk/cma-cases/private-healthcare-market-investigation).

The London School of Economics (LSE) research team comprises researchers from three research centres: LSE Health, Personal Social Services Research Unit (PSSRU), and the LSE Research Laboratory (RLAB). The legal entity that LSE Health belongs to is London School of Economics, as LSE Health is a multidisciplinary research centre in advancing global research in health policy and health economics, based within the University. The research team will use HES (Hospital Episode Statistics) and PROMs (Patient Related Outcome Measures) and Civil Registration Data to make four distinct contributions to health and social care within a single programme of research. The first contribution is to analyse the impact that various aspects of policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. The second contribution compares health care system performance in several countries with the aim of spreading best practice across different countries, with specific focus on lessons that can be learnt for health and social care policy within the NHS. The third contribution develops and tests a range of multi-dimensional indicators of health care quality and outcomes. The fourth contribution analyses the link between population-level exposures to environmental shocks and health outcomes.

The purpose of receiving the data is to analyse the impact of on-going NHS reforms implemented between 2000 and the present day using pseudonymised non-sensitive patient-level data (further details of these reforms are provided below). These reforms were primarily associated with the introduction of two Acts of Parliament (the National Health Service Act 2006 and the Health and Social Care Act 2012) that changed both the organisational and payment structures of the NHS. The second Act of Parliament relies on on-going productivity gains to maintain efficient NHS output. The objective of the research programme is to assess the change in policy direction arising from these reforms, to better understand the impact of these reforms on patient outcomes and to improve the measurement of the impact of these reforms and to aid the efficiency with which they are implemented.

London School of Economics requires access to an extract of Civil Registration mortality data because a key focus of the research is the effect of NHS reforms since 2000 on health care quality. LSE have produced many outputs that use mortality as an indicator of health care quality, but have hitherto been limited to examining in-hospital mortality rather than all-location mortality because of no previous access to linked mortality data. The fact that LSE only have data on deaths in hospital has introduced a small but significant source of potential bias to previous work focusing on mortality. For instance, if some hospitals discharge patients earlier than others, then they might appear to offer higher care quality as captured by lower in-hospital mortality rates, when in fact patients from these hospitals are simply dying at home rather than in hospital. While previous work (see e.g. Cooper et al. 2011, Economic Journal) has carefully discussed this potential source of bias to show that it is unlikely to drive the findings, a more comprehensive solution to this problem is to obtain data on all-location mortality. Linking Civil Registration data to HES will enable LSE to henceforth use all-location mortality as an indicator of care quality. This will improve the quality of research, and improve the ability of policymakers to confidently formulate policy changes aimed at improving health and social care that is informed by the findings of the research.

Research deliverables are currently underway to examine the impact of the following reforms to the NHS and include the following:

* Introduction of Payment by Results (2003-2006).

* Implementation of waiting time targets for first outpatient appointment, elective surgery, and A&E attendances (2001-2005).

* Introduction of the Quality and Outcomes Framework (2004).

* Introduction of patient choice of hospital and GP surgery (2006-2008).

* Introduction of independent care providers, both as part of the Independent Sector Treatment Centre programme and under the Any Qualified Provider programme (2003-2010).

* Introduction of Walk in Centres for ambulatory care (2000-2010).

* Introduction of the Alternative Provider of Medical Services GP contract (2004).

* Expansion of primary care provision under the Equitable Access to Primary Care initiative (2007-2010).

* Implementation of Equality and Human Rights Commission (EHRC) Memorandum of Understanding with the Care Quality Commission on equality and human rights in the context of healthcare (2011)

* Introduction of Clinical Commissioning Groups in place of Primary Care Trusts (2013-2014).

* Progress towards the Nicholson productivity challenge (2009-2015).

* Introduction of new signals of hospital outcomes and performance, including the NHS Choices website (2006), Patient Reported Outcome Measures (2009), the NHS Staff Survey (2003), and various NHS Patient Satisfaction and Patient Experience surveys.

Each of these research deliverables form part of the first contribution to health and social care outlined above, by analysing a specific policy introduced within the NHS over the last 15 years. Each of these deliverables also forms part of the third contribution to health and social care, in that each focuses on analysing the impact of a particular policy or reform on one or more multi-dimensional indicators of health care quality and outcomes.

The research team has primarily progressed the second contribution to health and social care – a cross-country comparison of health care system performance – via a project entitled “Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” that examines the impact of financial incentives on clinicians’ decisions in England and Scotland. Making further progress toward this second contribution to health and social care will be a major focus of the research programme over the next 2-3 years.

The research team intends to progress the fourth contribution to health and social care – analysing health responses to population-level exposures to environmental shocks such as pollution. A key aim of this fourth contribution is to estimate the causal relationship between ambient air pollution and hospital admissions. Another objective of this fourth contribution is to evaluate the health impact of the London Congestion Charge via changes in air quality in the London area. Specifically, the research team intend to investigate whether the introduction of the Congestion Charge and the subsequent change in air quality in London decreased the frequency and duration of hospital admissions for pollution-related diseases, particularly among sensitive groups such as infants and the elderly.

Using patient-level data is necessary for risk adjustment at the patient level, thereby allowing control of confounding factors that will affect the analysis. Using patient-level data is also necessary to construct various inputs into the analysis -- for example, percentiles of distance from patient's GP surgery to hospital of admission, which are needed to construct indices that define hospital referral markets and potential areas of competition. All programme outputs that have used data NHS Digital has provided have been aggregated with small number suppression in line with the HES analysis guide.

A significant portion of the research programme involves assessment of NHS reforms initiated during the first decade of the 2000s. To effectively assess these reforms, not only is data from these years required, but also, data from the pre-reform period is required, in order to establish a baseline against which subsequent health care provider behaviour and performance can be compared. For this reason, it is crucial to have data from 1996/1997 onwards.

Another core focus of the research programme is to assess efforts to increase NHS productivity in the years since 2010. These efforts were initially linked to the ’Nicholson challenge’ to find £20 billion in efficiency savings by 2015, but have continued since then in light of continued pressures on NHS funding. In order to pursue this aspect of our research programme, data from 2009/10 to the present are required.

A large number of the outputs produced as part of this research programme examine mortality as an outcome variable. HES provides data in deaths in hospital, but it does not provide data on deaths subsequent to discharge. Studies that examine mortality using only HES always face questions about the potential that their results are biased by the exclusive focus on in-hospital deaths, as the pattern of all-location mortality may be different to the pattern of in-hospital mortality. Linking HES data to mortality data will provide this research team with a comprehensive means of eliminating this potential source of bias, by allowing them to analyse all-location mortality rather than in-hospital mortality.

******

The request for additional years of data primarily pertains to the first purpose (analysing the impact of various aspects of policy-development and reform of the NHS), in the manner described below. However, access to more recent years of data will also enable LSE to further the new, fourth purpose (analysing the link between population-level exposures to environmental shocks and health outcomes) by enabling this analysis to be conducted using up-to-date data.

The first purpose is designed to inform current policy requirements. The more contemporaneous the data is, the better LSE can achieve this objective. The most recent years have also seen the greatest financial constraints, even accounting for some uplift payments, and the research team are most interested in documenting how the NHS has coped under this financial stringency. Below LSE outline three key areas where access to new years of data will be of particular value.

One policy implication of tightening budgets is in the interface between NHS hospital performance and the community care provided by Local Authorities. One strand of the on-going research on productivity, which will continue under a renewed grant from the DHSC to the LSE (and LSE have already presented some early results of this work to the DHSC), is concerned with how hospital discharge decisions are affected by the supply constraints faced by Local Authorities with regards to the provision of community care services. If there is insufficient supply of care in the community then, regardless of the efficiency gains achieved by hospitals in their discharge processes, bed-blocking will still occur. LSE require up-to-date HES data to document how these relationships have evolved under recent changes to NHS finances. LSE's aim is that this research will identify how the NHS and Local Authorities can coordinate care provision more effectively, thus contributing to improved hospital performance and more joined-up care.

A second strand of the first research purpose is examining patient choice as a means of delivering high quality health care within the NHS, as is articulated in the NHS Constitution. In particular, LSE are empirically analysing how patients and their GPs make elective surgery referral choices, and what specific signals of provider quality they react to. The research team know and can already document that waiting time for elective surgery has a major impact on choice of hospital. Over the past few years, waiting time targets have been missed by many providers. LSE will supplement existing work on patient choice to investigate how these missed targets have affected patient choice. LSE are particularly interested in assessing whether access to care for individuals in the most deprived areas has been more adversely affected by worsening targets, and whether there has been a measurable impact on health outcomes as a consequence. Access to data for more recent years, when achievement of waiting time targets has worsened considerably, is necessary to undertake this investigation.

A third strand of investigation necessitating up-to-date data relates to interest in productivity through an analysis of the up-take and diffusion of new health care technologies. In particular, LSE are examining how new technology either substitutes or complements existing technology. As referenced by the UK Office for Budget Responsibility (Fiscal Sustainability and Public Health Spending, September 2016), earlier work by LSE using HES data on two common surgical procedures (angioplasty and coronary artery bypass grafting) has shown that technological innovations are generally cost-escalating rather than cost-containing. LSE are in the process of extending this work to consider implications for labour input choices — both substitution between labour and capital, and substitution between different types of labour (physician specialities). LSE require access to new data to examine the diffusion of new health care technologies since 2014/15.

An aspect of this work is funded by The Health Foundation. The Health Foundation work is contributing to the first research purpose which is on the impact that policy-development and reform of the NHS have had on patient outcomes, waiting times, and provider behaviour. LSE are linking the up-take of new technology as guided by policy-development and assessing the impact that it has on new surgical procedures, patient outcomes and provider behaviour. Specifically LSE are considering the regulatory support for new surgical procedures as these new procedures will affect patient outcomes and provider behaviour, in this specific case the impact will be on provider workforce composition.

LSE have taken surgical procedures and related this to the impact on the NHS workforce by considering whether the surgical composition has changed as a result of the policy support, through NHS and NICE guidance, for new surgical techniques. For example, LSE are currently looking at the impact on provider behaviour, in terms of workforce composition, as Percutaneous Transluminal Coronary Angioplasty (PTCA) has replaced Coronary Artery By-Bass Grafting (CABG

.

A full re-supply of HES APC data will be given as part of this agreement - this is due to data quality issues that occurred with the last dissemination of HES APC data and the migration into the LSE system.

The expected outputs consist of research reports and published papers, and discussions and presentations to UK health and social care policymakers, policy analysts, and clinicians. A list of outputs to date is provided below. The primary target audience for these outputs is the health policy community. This includes policymakers, as a key aim of the research is to investigate the impact of recent changes to health and social care policy, with an ultimate objective of influencing future policy formation. However, it also includes other policy analysts, such as (but not limited to) those at the Health Foundation, the King’s Fund and Nuffield Trust, who, while they may not be directly involved in the policy formation process, do have an important influence over the terms under which health policy is debated and therefore formulated.

A secondary target audience is the medical community that has been responsible for implementing many of the policy reforms analysed, and whose decisions therefore determine the success of these reforms, and the nature of their impacts.

Another secondary target audience for the team's fourth contribution, on the link between population-level exposures to environmental shocks and health outcomes, is environmental policymakers -- for example those responsible for air pollution regulations. This fourth contribution aims to benefit health and social care by providing more rigorous evidence than is currently available concerning the effects on population health of environmental policies such as the London Congestion charge and the T-charge (emissions surcharge).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reform and health and social care outcomes. A few of these variables (e.g. whether a patient is discharged as dead) appear directly in HES, but most (e.g. length of hospital stay, patient severity aggregating across multiple diagnoses, hospital productivity, or intensity of competition to which a hospital is exposed) are constructed using multiple underlying HES variables. HES data will only feature directly in the outputs of these research projects in tables of summary statistics that report properties of key variables used in the analysis (such as minimum, maximum and average values).

No data or datasets using HES data will be published or made available, either at the individual patient level or at an aggregate level, as part of this programme of work. The data will not be used for any commercial purpose.

LSE hope to improve all such research by using the civil registration data to henceforth examine all-location mortality rather than in-hospital mortality.

A key part of the research programme is to assess the impact of the Health and Social Care Act 2012, and interrelated reforms. Examples of changes associated with this legislation that are being assessed include:

• 2012 introduction of Any Qualified Provider.

• 2013 introduction of Clinical Commissioning Groups.

• 2015 introduction of patient choice of General Practitioner.

• Phases 1 and 2 of the Quality, Innovation, Productivity and Prevention (QIPP).

• Effects of NHS contracting reforms on the relationship between hospital trusts and Local Authorities, with a particular focus on effects on bed blocking.

To assess these reforms, the research team require years of data from after their implementation. Many changes resulting from this legislation did not take effect until April 2013 and their full impact was not felt until some time after that. Obtaining data up to 2018/2019 will enable a comprehensive assessment of the impact of these reforms over time.

Several project outputs are already available in draft form, and are expected to be published in final form over the next 3 years.

Draft project outputs already produced

In this field of work, the life cycle of a research project can be roughly summarised as follows: work in progress presentation (slides only); unpublished mimeo; Working Paper (which may also be a final output, or may be progressed to academic journal submission); submission to academic journal (if relevant); and publication of final report or journal article. Irrespective of the final publication location, the research team takes substantial effort to disseminate its outputs by presenting findings to policymakers and policy analysts.

The following research projects are at work in progress stage:

•“Taking care of the budget? Clinical decisions and Patient Outcomes under recent NHS reforms”.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”.

• “Home for the Holidays: Evidence on the Relationship Between Prospective Payment, Length of Stay, and Patient Outcomes”.

The following research projects are at mimeo stage

•“The hospital as a multi-product firm: Measuring the effect of hospital competition on quality using Patient-Reported Outcome Measures”.

• “Independent Sector Treatment Centres in the English NHS: Effects on neighbouring NHS hospitals”.

The following research projects are at Working Paper stage:

•“Walk This Way: Estimating Impacts of Walk in Centres at Hospital Emergency Departments in the English National Health Service”, SERC Discussion Paper 167, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0167.pdf.

• “Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service”, CEP Discussion Paper 1125,

http://cep.lse.ac.uk/pubs/download/dp1125.pdf.

The following papers are under review for academic journal publication:

•“Do Financial Incentives Trump Clinical Guidance?: The case of Hip Replacements in England and Scotland” (for slides see: http://www.slideshare.net/OHENews/do-financial-incentives-trump-clinical-guidance-apr15).

• “Measuring and Forecasting Hospital Quality”.

Dissemination of draft project outputs

This is a non-exhaustive list of the formal and informal methods by which the Research Team has disseminated their draft project outputs to policymakers, policy analysts and clinicians.

Since 2013, draft outputs of the research projects have been disseminated directly to policymakers in the following ways:

• Seminar presentation to Department of Health, July 2015.

• Seminar presentation to Office of Health Economics, May 2015 (attended by representatives from Monitor and Department of Health).

• Presentation of research to Department of Health group, March 2015.

• Multiple meetings to report draft project outputs to representatives of Monitor and Department of Health.

In addition, the draft project outputs have been presented to the following fora that have been attended by policymakers and policy analysts:

• Health Economics Study Group (January 2015 and June 2016).

• Royal Economics Society Meeting (March 2015).

• LSE Spatial Economics Research Centre Conference (March 2015).

• LSE STICERD Work in Progress Seminar (October 2013) (attended by representatives of Royal College of Surgeons).

• Informal workshop involving representatives from King’s Fund, and former Prime Ministerial advisors and heads of regulatory bodies (June 2015).

• Joint LSE-Dartmouth College workshop on Medical Practice Variations (September 2014).

• LSE International Health Policy Conference 2017.

Finally, the research outputs have been reported in media sources widely read by health policymakers and thought leaders, including (this is a very incomplete list) the Health Services Journal, The Guardian, The New Statesman, The Daily Telegraph, and The Financial Times.

Update October 2017:

New Work in Progress

•“The relationship between new technologies and workforce in English hospitals”, October.

• “Do altruistic hospitals and profit-maximising hospitals respond differently to competition?”, April.

• “Patients’ choice and hospital quality competition: Unintended impacts of the signals”, October.

• “Coordinating Hospital Discharges: Bed Blocking in England”, October.

New Working Papers:

• “Taking Care of the Budget? Practice-level Outcomes during Commissioning Reforms in England”, SERC Discussion Paper 192, February, http://www.spatialeconomics.ac.uk/textonly/SERC/publications/download/sercdp0192.pdf.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service” CEP Discussion Paper 1434, June, http://cep.lse.ac.uk/pubs/download/dp1434.pdf.

• “The Hospital as a Multi-Product Firm: The Effect of Hospital Competition on Value-Added Indicators of Clinical Quality” CEP Discussion Paper 1484, May, http://cep.lse.ac.uk/pubs/download/dp1484.pdf.

New academic journal publications:

• “Coordinating Hospital Discharges: Bed Blocking in England”, Journal of Health Economics, accepted subject to revisions.

• “Does Competition from Private Surgical Centres Improve Public Hospitals’ Performance? Evidence from the English National Health Service”, Journal of Public Economics, accepted subject to revisions

•“Measuring and forecasting quality in English hospitals”, Journal of the Royal Statistical Society: Series A 180(2), February, pp.409-432, ISSN 0964-1998.

•“Do financial incentives trump clinical guidance? Hip replacement in England and Scotland”, Journal of Health Economics 44, pp.25-36, ISSN 0167-6296.

Since 2015, LSE have disseminated their research to individual contacts in NHS Improvement, Department of Health, the Department of Health's Economics of Social and Health Care Research Unit, the Competition and Markets Authority, and the Health Foundation.

In 2015, LSE presented their research on the tension between financial incentives and clinical guidance to a UK Government Department of Health Seminar.

In September 2015, LSE presented their research on the impacts of hospital competition to the Wennberg International Collaborative on unwarranted variations in health care utilisation and outcomes. This high-level forum included representatives from Monitor/ NHS Improvement, NHS England, and NHS Scotland, as well as senior representatives from other health care systems around the world.

In November 2016, LSE presented their research on the impact of new medical technologies within the NHS to the Health Foundation. This was a stepping stone to disseminating this research more widely to policymakers and the broader health policy community. This work is beginning to be recognised as a fundamental contribution to understanding the impact of technology dissemination on the NHS workforce. It has pioneered the estimation of labour substitutability or complementarity within the NHS as new technology is taken up. It has fed in to the Health Foundation initiative, based around the Department of Public Health at the University of Cambridge, where a workshop was run that included a large number of NHS managers concerning technology uptake and labour substitutability. In this way it has helped to disseminate best practice concerning technology uptake within the NHS

In May 2017, at the invitation of the UK Competition and Markets Authority (CMA), LSE presented their research on the impacts of hospital competition to an international conference of European competition regulators. The research team's findings have a direct impact on the decision-making process of competition regulators such as the CMA concerning hospital mergers. The LSE presented its findings to representatives of the following organisations:

• From the UK: the Competition and Markets Authority and NHS Improvement.

• From the Netherlands: the Authority for Competition and Markets, the Dutch Healthcare Authority, and the Ministry of Health.

• From Norway: the Competition Authority.

• From Germany: Bundeskartellamt (Federal Cartel Office).

• From France: Autorité de la concurrence (Competition Authority).

The main outputs of these reports and papers will be estimates of the statistical relationship between different variables and the pursuit of establishing causal linkages between policy reforms and environmental shocks with health and social care outcomes.

The main outcome of the presentation at the Wennberg International Collaborative was simply to raise awareness about the research findings amongst policymakers and practitioners.

Earlier work compiled by the research team (Cooper et al 2011) was cited by the then Prime Minister in support of the Health and Social Care Act 2012, which expanded choice and competition within the NHS. The research also helped to ensure that these reforms did not introduce price competition between health care providers, as had initially been proposed. The work on hospital quality and on choice and competition has been used by NHS Monitor (now NHS Improvement) in their measurement and analysis of hospital efficiency measurement, which forms one strand of their work to identify inefficient hospital trusts. The project lead has since worked with NHS Improvement to aid this strand of their work, and the work in this area also led to him becoming an adviser to the UK Competition and Markets Authority investigation into the Private Health Care Market which led to a range of measures being implemented in 2014 (see https://www.gov.uk/cma-cases/private-healthcare-market-investigation).