1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper...
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Transcript of 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper...
![Page 1: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/1.jpg)
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Centre for Market and Public Organisation
Health Care Reform: Evidence and Issues
Carol Propper
Public Service Reform Seminar March 2009
![Page 2: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/2.jpg)
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Recent NHS reforms
![Page 3: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/3.jpg)
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Late 1990s and early 2000s: targets
• Drive to increase quality and efficiency by extensive use of targets
• Examples – waiting times targets for inpatient care (from an initial 18
months!)– 4 hour targets for A and E waits– MRSA and hospital cleanliness– National Service frameworks
• Coronary Heart Disease National Service Framework - information strategy including information needs of patients, carers and the public; health professionals to deliver care; and clinical governance, performance management, service planning and public health.
![Page 4: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/4.jpg)
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2004 onwards: Competition
• Promotion of competition and choice• Components
– Gradual increase in choice of hospitals by patients– Use of private sector to provide care– PbR tariff mechanism
• Accompanying changes in roles– PCTs as commissioners of services, SHAs as strategic market
managers– The Panel on Cooperation and Competition - “The NHS’s own
version of the CC … will provide independent, expert advice on issues arising from this new competition policy” (Bradshaw Sept. 2008)
![Page 5: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/5.jpg)
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Evidence
![Page 6: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/6.jpg)
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Targets: the evidence
• Academic and popular literature stresses negative aspects of targets: “meeting the target and missing the point”
• Lots of anecdotal evidence of gaming• But … looking at waiting lists, the whole picture
and exploiting comparison with Scotland
![Page 7: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/7.jpg)
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Fig 1: Published and unpublished census data
Scotland vs England waiting times
![Page 8: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/8.jpg)
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• Some evidence of ‘managing the lists’ but no evidence of health effects
• Similar results for studies of A and E 4 hour waits
• Why did such targets appear to work?• Features of waiting times
– High visibility politically– Of concern to clinical staff and patients
• Targets may act as ‘missions’ around which employees can focus effort
![Page 9: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/9.jpg)
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Competition: the evidence
• Not much sign so far that competition has changed outcomes e.g. Aberdeen report – Fall in LOS, no impact on quality
• Behaviour has been slow to change in response to PbR– Lack of good costing systems
• But…– Is there scope for competition? How competitive are
markets?
![Page 10: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/10.jpg)
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Competition: the evidence
• US Department of Justice guidelines on competition– Market concentration is a function of the number of
firms in a market and their respective market shares. – “HHI” index of market concentration. – Divides market concentration into three regions
• unconcentrated (HHI below 1000) • moderately concentrated (HHI between 1000 and 1800)• highly concentrated (HHI above 1800)
– In concentrated markets an increase of 100 points may be presumed to create/enhance market power
![Page 11: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/11.jpg)
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Competition: the evidence
• How concentrated are English health care markets?
• Different products – maternity + emergency (people want to be treated
close to home)– Hips and knees (waiting times important, lots of
providers)– CABG (few providers, people have to travel)
• Define self contained markets (E-H) and the extent of concentration within these
![Page 12: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/12.jpg)
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Maternity admissions Emergency admissions
Self contained markets in maternity and emergency
![Page 13: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/13.jpg)
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Hip and knee replacements CABG procedures
Self contained markets in hip and knee and CABG
![Page 14: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/14.jpg)
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Maternity
admissionsEmergency admissions
Hip and knee replacements
CABG procedures
Number of providers (with at least 50) 157 148 159 30
Herfindahl-Hirschman Index
Mean 6209 6516 3299 1490
Median 6225 6068 1157 992
Mean distance travelled by patient 9.8 14.5 15.0 36.6
Mean number of providers used by a PCT 19.1 6.7 8.4 2.7
![Page 15: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/15.jpg)
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Competition: the evidence
• English health care markets are concentrated• Concentration is not a function of lack of number of
providers– Less competition in maternity and elective where there are lots of
markets and in each a few suppliers are dominant– markets that might be thought to be more competitive because
there are more suppliers (hips + knees) are less competitive than CABG
• Extent of concentration reflects patients’ willingness to travel, which in turn reflects their need and the existing number of suppliers
• Implications – mergers could lead to more abuse of market power in maternity (where there are many suppliers) than in CABG (where there are few)
![Page 16: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/16.jpg)
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The issues
![Page 17: 1 Centre for Market and Public Organisation Health Care Reform: Evidence and Issues Carol Propper Public Service Reform Seminar March 2009.](https://reader035.fdocuments.in/reader035/viewer/2022081518/5515fcef550346d46f8b5969/html5/thumbnails/17.jpg)
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• Concentration in English health care markets is high – If hospitals seek to merge to avoid competition this
will increase concentration in already concentrated markets
• Lack of competition is not a function of lack of suppliers
• Patient behaviour will have to change to reduce competition or supply will have to increase considerably– Are patients willing to travel more?– Do the PbR tariffs make this profitable?
• Lots of issues for the Carter Commission!