The demand for elective surgery in a public system: time and money prices in the UK National Health Service

How do family doctors respond to reduced waiting times for cancer diagnosis in secondary care?

Reducing waiting times is a priority in public health systems. Efforts of healthcare providers to shorten waiting times could be negated if they simultaneously induce substantial increases in demand. However, separating out the effects of changes in supply and demand on waiting times requires an exogenous change in one element. We examine the impact of a pilot programme in some English hospitals to shorten waiting times for urgent diagnosis of suspected cancer on family doctors' referrals. We examine referrals from 6,666 family doctor partnerships to 145 hospitals between 1st April 2012 and 31st March 2019. Five hospitals piloted shorter waiting times initiatives in 2017. Using continuous difference-in-differences regression, we exploit the pilot as a 'supply shifter' to estimate the effect of waiting times on referral volumes for two suspected cancer types: bowel and lung. The proportion of referred patients breaching two-week waiting times targets for suspected bowel cancer fell by 3.9 percentage points in pilot hospitals in response to the policy, from a baseline of 4.8%. Family doctors exposed to the pilot increased their referrals (demand) by 10.8%. However, the pilot was not successful for lung cancer, with some evidence that waiting times increased, and a corresponding reduction in referrals of -10.5%. Family doctor referrals for suspected cancer are responsive at the margin to waiting times. Healthcare providers may struggle to achieve long-term reductions in waiting times if supply-side improvements are offset by increases in demand.

Who responds to longer wait times? The effects of predicted emergency wait times on the health and volume of patients who present for care

Healthcare is often free at the point-of-care so that price does not deter patients. However, the dis-utility from waiting for care that often occurs could also lead to deterrence. I investigate responses in the volume and types of patients that demand emergency care when predicted waiting times quasi-randomly change. I leverage a discontinuity to compare emergency sites with similar predicted wait times but with different apparent wait times displayed to patients. I use impulse response functions estimated by local projections to estimate effects of predicted wait times on patient demand for care. An additional thirty minutes of predicted wait time results in 15% fewer waiting patients at urgent cares and 2% fewer waiting patients at emergency departments within three hours of display. Patients that stop using emergency care are also triaged as healthier. However, at very high predicted wait times, there are reductions in demand for all patients including sicker patients.

The effect of local hospital waiting times on GP referrals for suspected cancer

INTRODUCTION

Reducing waiting times is a major policy objective in publicly-funded healthcare systems. However, reductions in waiting times can produce a demand response, which may offset increases in capacity. Early detection and diagnosis of cancer is a policy focus in many OECD countries, but prolonged waiting periods for specialist confirmation of diagnosis could impede this goal. We examine whether urgent GP referrals for suspected cancer patients are responsive to local hospital waiting times.

METHOD

We used annual counts of referrals from all 6,667 general practices to all 185 hospital Trusts in England between April 2012 and March 2018. Using a practice-level measure of local hospital waiting times based on breaches of the two-week maximum waiting time target, we examined the relationship between waiting times and urgent GP referrals for suspected cancer. To identify whether the relationship is driven by differences between practices or changes over time, we estimated three regression models: pooled linear regression, a between-practice estimator, and a within-practice estimator.

RESULTS

Ten percent higher rates of patients breaching the two-week wait target in local hospitals were associated with higher volumes of referrals in the pooled linear model (4.4%; CI 2.4% to 6.4%) and the between-practice estimator (12.0%; CI 5.5% to 18.5%). The relationship was not statistically significant using the within-practice estimator (1.0%; CI -0.4% to 2.5%).

CONCLUSION

The positive association between local hospital waiting times and GP demand for specialist diagnosis was caused by practices with higher levels of referrals facing longer local waiting times. Temporal changes in waiting times faced by individual practices were not related to changes in their referral volumes. GP referrals for diagnostic cancer services were not found to respond to waiting times in the short-term. In this setting, it may therefore be possible to reduce waiting times by increasing supply without consequently increasing demand.

Optimal hospital payment rules under rationing by waiting

We derive optimal rules for paying hospitals for non-emergency care when providers choose quality and capacity, and patient demand is rationed by waiting time. Waiting for treatment is costly for patients, so that hospital payment rules should take account of their effect on waiting time as well as on quality. Since deterministic waiting time models imply that profit maximising hospitals will never choose to have both positive quality and positive waiting time, we develop a stochastic model of rationing by waiting in which both quality and expected waiting are positive in equilibrium. We use it to show that, although a prospective output price gives hospitals an incentive to attract patients by raising quality and reducing waiting times, it must be supplemented by a price attached to hospital decisions on quality or capacity or to a performance indicator which depends on those decisions (such as average waiting time, or average length of stay). A prospective output price by itself can support the optimal quality and waiting time distribution only if the welfare function respects patient preferences over quality and waiting time, if patients' marginal rates of substitution between quality and waiting time are independent of income, and if waiting for treatment does not reduce the productivity of patients. If these conditions do not hold, supplementing the output price with a reward linked to the hospital's cost can increase welfare, though it is possible that costs should be taxed rather than subsidised.

Should I stay or should I go? Hospital emergency department waiting times and demand

In the absence of the price mechanism, hospital emergency departments rely on waiting times, alongside prioritisation mechanisms, to restrain demand and clear the market. This paper estimates by how much the number of treatments demanded is reduced by a higher waiting time. I use variation in waiting times for low-urgency patients caused by rare and resource-intensive high-urgency patients to estimate the relationship. I find that when waiting times are higher, more low-urgency patients are deterred from treatment and leave the hospital during the waiting period without being treated. The waiting time elasticity of demand for low-urgency patients is approximately -0.25 and is highest for the lowest-urgency patients.

The effect of waiting times on demand and supply for elective surgery: Evidence from Italy

Waiting times are a major policy concern in publicly funded health systems across OECD countries. Economists have argued that, in the presence of excess demand, waiting times act as nonmonetary prices to bring demand for and supply of health care in equilibrium. Using administrative data disaggregated by region and surgical procedure over 2010-2014 in Italy, we estimate demand and supply elasticities with respect to waiting times. We employ linear regression models with first differences and instrumental variables to deal with endogeneity of waiting times. We find that demand is inelastic to waiting times while supply is more elastic. Estimates of demand elasticity are between -0.15 to -0.24. Our results have implications on the effectiveness of policies aimed at increasing supply and their ability to reduce waiting times.

Choice of hospital: Which type of quality matters?

The implications of hospital quality competition depend on what type of quality affects choice of hospital. Previous studies of quality and choice of hospitals have used crude measures of quality such as mortality and readmission rates rather than measures of the health gain from specific treatments. We estimate multinomial logit models of hospital choice by patients undergoing hip replacement surgery in the English NHS to test whether hospital demand responds to quality as measured by detailed patient reports of health before and after hip replacement. We find that a one standard deviation increase in average health gain increases demand by up to 10%. The more traditional measures of hospital quality are less important in determining hospital choice.

Supplementing gatekeeping with a revenue scheme for secondary care providers

We study implications of a change in the payment scheme for radiology providers in Norway that was implemented in 2008. The change implies reduced fee-for-service and increased fixed budget for a contracted volume of services. A consequence of the change is that private providers have less incentive to conduct examinations beyond the contracted volume. Different from the situation observed before the change in 2008, the volume is no longer determined by the demand side, and a rationing of the supply occurs. We employ data on radiological examinations initiated by GPs' referrals. We apply monthly data at the physician-practice level for 2007-2010. The data set is unique because it includes information about all GPs in the Norwegian patient-list system. The results indicate that private providers conducted fewer examinations in 2008-2010 compared with previous periods and that public hospitals did either the same volume or more. We find that GPs who operate in a more competitive environment experienced a greater reduction in magnetic resonance imaging, both performed by private providers and in total for their patients. We argue that this result supports a hypothesis that patients with lower expected benefits are rationed. Hence, rationing from the supply side might supplement GP gatekeeping.

Waiting time distribution in public health care: empirics and theory

Excessive waiting times for elective surgery have been a long-standing concern in many national healthcare systems in the OECD. How do the hospital admission patterns that generate waiting lists affect different patients? What are the hospitals characteristics that determine waiting times? By developing a model of healthcare provision and analysing empirically the entire waiting time distribution we attempt to shed some light on those issues. We first build a theoretical model that describes the optimal waiting time distribution for capacity constraint hospitals. Secondly, employing duration analysis, we obtain empirical representations of that distribution across hospitals in the UK from 1997-2005. We observe important differences on the 'scale' and on the 'shape' of admission rates. Scale refers to how quickly patients are treated and shape represents trade-offs across duration-treatment profiles. By fitting the theoretical to the empirical distributions we estimate the main structural parameters of the model and are able to closely identify the main drivers of these empirical differences. We find that the level of resources allocated to elective surgery (budget and physical capacity), which determines how constrained the hospital is, explains differences in scale. Changes in benefits and costs structures of healthcare provision, which relate, respectively, to the desire to prioritise patients by duration and the reduction in costs due to delayed treatment, determine the shape, affecting short and long duration patients differently. JEL Classification I11; I18; H51.

Hospital sector choice and support for public hospital care in New Zealand: Results from a labeled discrete choice survey

This study uses a discrete choice experiment (DCE) to measure patients' preferences for public and private hospital care in New Zealand. A labeled DCE was administered to 583 members of the general public, with the choice between a public and private hospital for a non-urgent surgery. The results suggest that cost of surgery, waiting times for surgery, option to select a surgeon, convenience, and conditions of the hospital ward are important considerations for patients. The most important determinant of hospital choice was whether it was a public or private hospital, with respondents far more likely to choose a public hospital than a private hospital. The results have implications for government policy toward using private hospitals to clear waiting lists in public hospitals, with these results suggesting the public might not be indifferent to policies that treat private hospitals as substitutes for public hospitals.

The commissioning reforms in the English National Health Service and their potential impact on primary care

Reform of the National Health Service in England will increase power and responsibility for family doctors. They will have a larger role in planning and buying health care including control of substantial budgets. This article examines the likely implications of the proposed reforms for primary care, and in particularly for family doctors. This article considers the effect of the new clinical role in commissioning health care, changes to the accountability structures, and the effect on competition and integration within health services. It also considers the effect of new financial incentives and the possibility of creating conflicts of interest.

The effect of waiting time and distance on hospital choice for English cataract patients

This paper applies latent-class multinomial logit models to the choice of hospital for cataract operations in the UK NHS. We concentrate on the effects of travel time and waiting time and especially on estimating the waiting time elasticity of demand. Models including hospital fixed effects rely on changes over time in waiting time to indentify coefficients. We show how using a latent-class multinomial logit model characterises the unobserved heterogeneity in GP practices' choice behaviour and affects the estimated elasticities of travel time and waiting time. The models estimate waiting time elasticities of demand of approximately -0.1, comparable with previous waiting time-demand models. For the average waiting time elasticity, the simple multinomial logit models are good approximations of the latent-class logit results.

Waiting-time targets in the healthcare sector: how long are we waiting?

Waiting-time targets are used by policy makers to monitor providers' performance. Such targets are based on the distribution of the patients on the list. We compare and link such distribution with the distribution of waiting time of patients treated, as opposed to on the list, which is a better measure of total disutility from waiting (although can only be calculated retrospectively). We show that the latter can be calculated from the former, and vice versa. We also show that, depending on how the hazard rate varies with time waited, the proportion of patients on the list waiting more than x periods can be higher or lower than the proportion of patients treated waiting more than x periods. However, empirically we find that the proportion of patients waiting on the list more than x months is smaller than our estimate of the proportion of patients treated waiting more than x months.

Rationing the public provision of healthcare in the presence of private supplements: evidence from the Italian NHS

In this paper we assess the relative effectiveness of user charges and administrative waiting times as a tool for rationing public healthcare in Italy. We measure demand elasticities by estimating a simultaneous equation model of GP primary care visits, public specialist consultations and private specialist consultations, as if they were part of an incomplete system of demand. We find that for public specialist consultations, own price elasticity of demand is about -0.3, while elasticity to administrative waiting time is about -.04. No substitution exists between the demand for public and private specialists, so that user charges act as a net deterrent for over-consumption. The public provision of healthcare does not induce the wealthy to opt out. Moreover our evidence suggests that user charges and waiting lists do not serve redistributive purposes.

Organizational reform and health-care goods: concerns about marketization in the UK NHS

This paper uses the recent history of marketization and privatization in the UK National Health Service as a case study through which to explore the relationship between health-care organization and health-care goods. Phases and processes of marketization are briefly reviewed in order to show that, although the scope of both marketization and privatization reforms have, until recently, been very heavily circumscribed (and can only be understood in the context of the rise of managerialism), they have nonetheless had a major impact on the "value field" of UK health services. The second half of the paper draws upon the concerns of the critics of market-style reforms to set out and explore the ways in which organizational reform and the shifts in institutional norms consequent upon it construct health-care goods and argues that the investigation of this organization-goods axis ought to have a central place in health-care ethics.

Ramsey waits: allocating public health service resources when there is rationing by waiting

The optimal allocation of a public health care budget across treatments must take account of the way in which care is rationed within treatments since this will affect their marginal value. We investigate the optimal allocation rules for public health care systems where user charges are fixed and care is rationed by waiting. The optimal waiting time is higher for treatments with demands more elastic to waiting time, higher costs, lower charges, smaller marginal welfare loss from waiting by treated patients, and smaller marginal welfare losses from under-consumption of care. The results hold for a wide range of welfarist and non-welfarist objective functions and for systems in which there is also a private health care sector. They imply that allocation rules based purely on cost effectiveness ratios are suboptimal because they assume that there is no rationing within treatments.

Explaining trends in concentration of healthcare commissioning in the English NHS

In recent years there have been marked changes in organisational structures and budgetary arrangements in the English National Health Service, potentially altering the relationships between purchasers (primary care organisations (PCOs) and general practices) and hospitals. We show that elective admissions from PCOs and practices became significantly more concentrated across hospitals between 1997/98 and 2002/03. There was a reduction in the average number of hospitals used by PCOs (16.7-14.2), an increase in the average share of admissions accounted for by the main hospital (49-69%), and an increase in the average Herfindahl index (0.35-0.55). About half the increase in concentration arose from the increase in the number of purchasing organisations as 100 health authorities were replaced by 303 primary care trusts. Most of the remainder was probably due to hospital mergers. Fundholding general practices that held budgets for elective admissions had less concentrated admission patterns than non-fundholders whose admissions were paid for by their PCO. Around 1/10th of the increase in concentration at practice level was due to the abolition of fundholding in April 1999. Our results have implications for the effects of the recent reintroduction of fundholding and the halving of the number of PCOs.

What's in a wait?

The current paper reviews and contrasts a management science view of waiting for healthcare, which centres on queues as devices for buffering demand, with an economic view, which stresses the role of the incentive structure, in the context of English Accident and Emergency Departments. We demonstrate that the management science view provides insight into waiting time performance within a single facility but is limited in its ability to shed light on variations in performance across facilities. We argue, with reference to supporting data, that such variations may be explainable by a proper understanding of the incentive structure in A&E Departments.

Is waiting-time prioritisation welfare improving?

Rationing by waiting time is commonly used in health care systems with zero or low money prices. Some systems prioritise particular types of patient and offer them lower waiting times. We investigate whether prioritisation is welfare improving when the benefit from treatment is the sum of two components, one of which is not observed by providers. We show that positive prioritisation (shorter waits for patients with higher observable benefit) is welfare improving if the mean observable benefit of the patients who are indifferent about receiving the treatment is smaller than the mean observable benefit of the patients who receive the treatment. This is true (a) if the distribution of the unobservable benefit is uniform for any distribution of the observable benefit; or (b) if the distribution of the observable benefit is uniform and the distribution of the unobservable benefit is log-concave. We also show that prioritisation is never welfare increasing if and only if the distribution of unobservable benefit is negative exponential.

The impact of budgets for gatekeeping physicians on patient satisfaction: evidence from fundholding

Between 1991 and 1998 English general practices had the option of holding budgets for prescribing and elective secondary care. Fundholding was reintroduced in 2005. We examine the effect of fundholding on patients' satisfaction with their practice, using a cross section of 4441 patients from 60 practices in the last year of fundholding (1998). We employ instrumental variables to allow for the endogeneity of fundholding. Patients of fundholders were less satisfied with the opening hours of their practice, their GP's knowledge of their medical history, with their GP's ability to arrange tests and willingness to refer to a specialist, and were more likely to agree that their doctor was more concerned about keeping costs down. Fundholder practices performed better on a number of process measures of care, and fundholding patients were more satisfied with additional non-medical services provided by the practice. The probability that patients were overall at least very satisfied with their GP practice was 0.073 (95% CI, 0.009-0.138) smaller in fundholding practices.

The market for elective surgery: joint estimation of supply and demand

This paper develops models of the demand for and supply of elective (non-emergency) surgery using a panel of quarterly data for 200 English hospitals over the period 1995-2002. Unusually, distinct measures of supply (outpatients seen and inpatient admissions) and demand (outpatient referrals and decisions to admit) are available for each observation. These offer the opportunity to estimate separate empirical models of supply and demand using ordinary least squares (OLS) regression methods. However, the strong correlation between the residuals of these models suggests some merit in the deployment of seemingly unrelated regression (SUR) methods. Although both static and dynamic SUR estimations leave the results largely qualitatively unchanged, SUR estimation can have a considerable quantitative effect relative to the OLS results. For example, SUR estimation generates a lower elasticity of inpatient demand with respect to waiting time than that obtained via OLS. The results offer an important justification for more careful econometric modelling of hospital behaviour than has traditionally been employed in the health economics literature.

The effect of financial incentives on gatekeeping doctors: evidence from a natural experiment

In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders' admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders' chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID).

Comparing the welfare effects of public and private health care subsidies in the United Kingdom

We use a calibrated analytical model to compare the welfare costs (gross of externalities) of increasing subsidies for public and private health care in the UK. The model incorporates wait costs for rationed public care, burdens that subsidies impose on the tax system, and distributional weights for different households. Welfare costs are significantly higher for expanding public health care over a range of parameter scenarios. Both policies reduce average wait times, but for public health care this is offset by new waiting costs incurred on extra treatments. And the burden on the tax system is much larger for expanding public health care.

Utilization of public health centres in Portugal: effect of time costs and other determinants. Finite mixture models applied to truncated samples

The impact of time costs on the utilization of medical care has been a subject of theoretical and empirical research since the early 1970s. The main goal of this paper is to show the effect of time costs on the number of visits to general practitioners (GP) in Portuguese public health centres. We measured the elasticity of primary health care utilization relative to the total time spent in the health centre and relative to travel time. We also provided evidence regarding the impact of an appointment delay on the utilization of public GP services. Our data resulted from the application of an endogenous sampling scheme, resulting in a truncated-at-zero data set. To model our dependent variable, number of visits, and accounting for the truncated nature of the data we used a finite mixture model specification. The data were obtained from the most recent implementation in Portugal of the 2003/2004 Europep Survey. The two-component negative binomial II finite mixture model led to the identification of two different latent classes of health centre users: a low-users class that comprises 88% of patients with an estimated utilization mean of 4.3 GP visits per year and a frequent-users class with an estimated utilization mean of 11.1 visits for the remaining 12% of the population. We failed to find any statistically significant elasticity of time cost utilization, when this variable is measured as the total time spent in the health centre. Regarding the effect of an appointment delay on health centre utilization we concluded that individuals respond to this variable by lowering the number of GP visits. This last finding may have policy implications, which will be discussed at the end of the paper.

Waiting lists, waiting times and admissions: an empirical analysis at hospital and general practice level

We report an empirical analysis of the responses of the supply and demand for secondary care to waiting list size and waiting times. Whereas previous empirical analyses have used data aggregated to area level, our analysis focuses on the supply responses of a single hospital and the demand responses of the GP practices it serves, and distinguishes between first outpatient visits, inpatient admissions, day-case treatment and emergency admissions. The results are plausible and in line with the theoretical model. For example: the demand from practices for first outpatient visits is negatively affected by waiting times and distance to the hospital. Increases in waiting times and waiting lists lead to increases in supply; the supply of elective inpatient admissions is affected negatively by current emergency admissions and positively by lagged waiting list and waiting time. We use the empirical results to investigate the dynamic responses to one off policy measures to reduce waiting times and lists by increasing supply.

Information asymmetry, insurance, and the decision to hospitalize

We analyze the problem of second-best optimal health insurance in the context of a model in which patients and doctors must decide not only on an aggregate quantity of health services to use in treating various kinds of illness, but also have a choice between different kinds of providers (in particular, outpatient services rendered by primary-care physicians or inpatient services provided by hospital-based specialists). We consider well-informed patients' choices of provider when they have conventional insurance so they only pay part of the cost of their health services, as well as the equilibrium strategies of doctors and patients when there is patient-provider asymmetry; in the latter case we also analyze a managed-care insurance setup under which doctors are paid by capitation. We find that under certain plausible conditions, second-best optimal managed-care plans with supply-side incentives dominate second-best optimal conventional plans that rely on cost control through demand-side cost sharing.

Private medical insurance and saving: evidence from the British Household Panel Survey

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.

Global burden of trachoma and economics of the disease

Interest in the economics of trachoma is high because of the refinement of a strategy to control trachomatous blindness, an ongoing global effort to eliminate incident blindness from trachoma by 2020, and an azithromycin donation program that is a component of trachoma control programs in several countries. This report comments on the economic distribution of blindness from trachoma and adds insight to published data on the burden of trachoma and the comparative costs and effects of trachoma control. Results suggest that 1) trichiasis without visual impairment may result in an economic burden comparable to trachomatous low vision and blindness so that 2) the monetary burden of trachoma may be 50% higher than conservative, published figures; 3) within some regions more productive economies are associated with less national blindness from trachoma; and 4) the ability to achieve a positive net benefit of trachoma control depends importantly on the cost per dose of antibiotic.

Hospital competition, GP fundholders and waiting times in the UK internal market: the case of elective surgery

In this paper I model the demand for and supply of elective surgery using a modified Hotelling framework in which time, money, and distance are determinants of the demand for hospital care. Hospitals compete with each other in terms of the waiting time and consequently treat a certain number of patients. The basic model of hospital competition is then extended to incorporate the general practitioner (GP) fundholding scheme whereby the GPs are allocated a budget with which to buy care for their patients. Waiting time increases when production of care becomes more expensive, when the benefit obtained from treatment increases, when the unit cost of distance decreases, and when the importance given to time as a performance indicator decreases. The higher the money price the lower the waiting time. Finally, the money price paid by the GP fundholders is greater than that paid by the Health Authorities and greater than the hospitals marginal cost of production. As a consequence, fundholding patients pay a zero time price while non-fundholding patients experiment a positive waiting time.

Modelling supply and demand influences on the use of health care: implications for deriving a needs-based capitation formula

Many health-care systems allocate funding according to measures of need. The utilisation approach for measuring need rests on the assumptions that use of health care is determined by demand and supply and that need is an important element of demand. By estimating utilisation models which allow for supply it is possible to isolate the socio-economic and health characteristics which affect demand. A subset of these variables can then be identified by a combination of judgement and further analysis as needs variables to inform funding allocations. We estimate utilisation models using newly assembled data on admissions to acute hospitals, measures of supply, morbidity and socio-economic characteristics for 8414 small geographical areas in England. We make a number of methodological innovations including deriving additional measures of specific morbidities at small area level from individual level survey data. We compare models with different specifications for the effect of waiting times and provider characteristics, with total, planned and unplanned hospital admissions, and estimated at small area (ward) and primary care organisation (general practice) level. After allowing for waiting times, distance, capacity and the availability of private health care, measures of mortality, self-reported morbidity, low education and low income increase the use of health care. We find evidence of horizontal inequity with respect to ethnicity and employment and suggest a method for reducing its effects when deriving a needs-based allocation formula.

The impact of accessibility on the use of specialist health care in Norway

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.

Use of referral reply letters for continuing medical education: a review

INTRODUCTION

Referrals between generalists and specialists are a central component of the health care system and necessitate effective communication between the involved providers. Despite the high prevalence of patient referrals and their crucial role in continuity and quality of care, the medical literature demonstrates that generalists may receive little or no information about the care their patients received and little information about the appropriateness of the referral or recommendations for follow-up care. General practitioners (GPs) prefer teaching that is directly related to their clinical work rather than traditional continuing education such as formal lectures. The purpose of this review is to assess the role of referral reply letters in the continuing education of GPs.

METHODS

A comprehensive literature search was conducted to November 2001 using MEDLINE, EMBASE, the Cochrane Library, and the Research and Development Resource Base developed by Continuing Education, Faculty of Medicine, University of Toronto, to identify studies that examined the use of referral letters for the transfer of information from specialists to referring physicians. Data on methodology, unit of analysis, main outcome measures, and results were extracted.

RESULTS

Of 1,250 articles retrieved, 9 met the eligibility criteria. Three of these analyzed the content of referral reply letters and 6 described the results of surveys of general and specialty physicians.

DISCUSSION

Little educational content is currently included in letters from specialists to referring GPs. GPs are receptive to the use of referral replies as sources of learning.