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Almeida ÁS. The role of private non-profit healthcare organizations in NHS systems: Implications for the Portuguese hospital devolution program. Health Policy 2017; 121:699-707. [PMID: 28433325 DOI: 10.1016/j.healthpol.2017.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/08/2016] [Accepted: 03/24/2017] [Indexed: 11/26/2022]
Abstract
The national health services (NHS) of England, Portugal, Finland and other single-payer universalist systems financed by general taxation, are based on the theoretical principle of an integrated public sector payer-provider. However, in practice one can find different forms of participation of non-public healthcare providers in those NHS, including private for profit providers, but also third sector non-profit organizations (NPO). This paper reviews the role of non-public non-profit healthcare organizations in NHS systems. By crossing a literature review on privatization of national health services with a literature review on the comparative performance of non-profit and for-profit healthcare organizations, this paper assesses the impact of contracting private non-profit healthcare organizations on the efficiency, quality and responsiveness of services, in public universal health care systems. The results of the review were then compared to the existing evidence on the Portuguese hospital devolution to NPO program. The evidence in this paper suggests that NHS health system reforms that transfer some public-sector hospitals to NPO should deliver improvements to the health system with minimal downside risks. The very limited existing evidence on the Portuguese hospital devolution program suggests it improved efficiency and access, without sacrificing quality.
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Affiliation(s)
- Álvaro S Almeida
- CEF.UP and Faculdade de Economia, Universidade do Porto, Rua Dr. Roberto Frias, 4200-464 Porto, Portugal.
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Cookson R, Asaria M, Ali S, Ferguson B, Fleetcroft R, Goddard M, Goldblatt P, Laudicella M, Raine R. Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04260] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.ObjectivesThe objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.DesignLongitudinal whole-population study at the small-area level.SettingEngland from 2001/2 to 2011/12.ParticipantsA total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.Main outcome measuresSlope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.Data sourcesPractice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).ResultsBetween 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.LimitationsGeneral practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.ConclusionsNHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.Future workExploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, UK
| | - Shehzad Ali
- Centre for Health Economics, University of York, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Brian Ferguson
- Knowledge and Intelligence, Public Health England, York, UK
| | | | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Peter Goldblatt
- Institute of Health Equity, University College London, London, UK
| | | | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
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Asaria M, Ali S, Doran T, Ferguson B, Fleetcroft R, Goddard M, Goldblatt P, Laudicella M, Raine R, Cookson R. How a universal health system reduces inequalities: lessons from England. J Epidemiol Community Health 2016; 70:637-43. [PMID: 26787198 PMCID: PMC4941190 DOI: 10.1136/jech-2015-206742] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/30/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period. METHODS Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare. RESULTS Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare. CONCLUSIONS Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.
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Affiliation(s)
- Miqdad Asaria
- Centre for Health Economics, University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | | | | | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Peter Goldblatt
- Institute of Health Equity, University College London, London, UK
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Vittal Katikireddi S, McKee M, Craig P, Stuckler D. The NHS reforms in England: four challenges to evaluating success and failure. J R Soc Med 2014; 107:387-92. [PMID: 25271273 PMCID: PMC4206642 DOI: 10.1177/0141076814550358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Srinivasa Vittal Katikireddi
- Evaluation of Social Interventions Programme, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G2 3QB, UK
| | - Martin McKee
- European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Peter Craig
- Evaluation of Social Interventions Programme, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G2 3QB, UK
| | - David Stuckler
- Department of Sociology, University of Oxford, Oxford OX1 3UQ, UK
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Mays N. Evaluating the Labour Government's English NHS health system reforms: the 2008 Darzi reforms. J Health Serv Res Policy 2014; 18:1-10. [PMID: 24121832 DOI: 10.1177/1355819613499323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Starting in 2002, the UK Labour Government of 1997-2010 introduced a series of changes to the National Health Service (NHS) in England designed to increase patients' choices of the place of elective hospital care and encourage competition among public and private providers of elective hospital services for NHS-funded patients. In 2006, the Department of Health initiated the Health Reform Evaluation Programme (HREP) to assess the impact of the changes. In June 2008, the White Paper, High quality care for all, was published. It represented the government's desire to focus the next phase of health care system reform in England as much on the quality of care as on improving its responsiveness and efficiency. The 2008 White Paper led to the commissioning of a further wave of evaluative research under the auspices of HREP, as follows: an evaluation of the implementation and outcomes of care planning for people with long-term conditions; an evaluation of the personal health budget pilots; an evaluation of the implementation and outcomes of the Commissioning for Quality and Innovation (CQUIN) framework; and an evaluation of cultural and behavioural change in the NHS focused on ensuring high quality care for all. This Supplement includes papers from each project. The evaluations present a mixed picture of the impact and success of the 2008 reforms. All the studies identify some limitations of the policies in the White Paper. The introduction of personal health budgets appears to have been the least problematic and, depending on assumptions, likely to be cost-effective for the sorts of patients involved in the pilot. For the rest of the changes, impacts ranged from little or none (CQUIN and care planning for people with chronic conditions) to patchy and highly variable (instilling a culture of quality in acute hospitals) in the three years following the publication of the White Paper. On the other hand, each of the studies identifies important insights relevant to modifying and improving the policies. These findings have continuing relevance since both the 2008 White Paper's policies, and the issues they were focused on remedying, remain central to the current Coalition Government's reform agenda.
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Affiliation(s)
- Nicholas Mays
- Professor of Health Policy, Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
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Tan S, Mays N. Impact of initiatives to improve access to, and choice of, primary and urgent care in the England: a systematic review. Health Policy 2014; 118:304-15. [PMID: 25106068 DOI: 10.1016/j.healthpol.2014.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/14/2014] [Accepted: 07/16/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND There were ten initiatives in the primary and urgent care system in the English NHS during the New Labour government, 1997-2010, aimed at delivering higher quality, more accessible and responsive care by expanding access, increasing convenience and introducing greater patient choice of provider. We examine their impact on demand, equity, patient satisfaction, referrals, and costs. METHODS Studies were systematically identified through electronic databases and reference lists of publications. Studies of all designs were included if published between 1997 and 2013, and with empirical data on the impacts above. RESULTS Nineteen studies of ten initiatives were included. Innovations often overlapped, complicating care. There was some demand for new provision on grounds of convenience, but little evidence of substitution between services. Patient satisfaction varied across schemes. There was little evidence on the costs and benefits of new versus existing provision. CONCLUSION New services generated a more complex system where new and existing providers delivered overlapping services. The new provision did not induce substitution and was likely to have increased overall demand. Initiatives to improve access to existing provision may have greater potential to improve access and convenience at lower marginal costs than developing new forms of provision.
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Affiliation(s)
- Stefanie Tan
- Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, United Kingdom.
| | - Nicholas Mays
- Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, United Kingdom
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