The National Health Service (NHS) has always been accompanied by some private practice of medicine, largely by practitioners who work mainly for the NHS, but to some extent by practitioners wholly outside NHS. The ideological issues in the provision of health care have been admirably dissected by Donabedian. His 'viewpoint A' may loosely be termed the 'libertarian' approach, under which access to health care is part of society's reward system, and, at the margin at least, people should be permitted to use their income and wealth to gain more or better health care if they so desire. His 'viewpoint B' may loosely be termed the 'egalitarian' approach, under which access to health care is a citizen's right, which ought not to be influenced by income and wealth. At a fundamental level, pure Paretian welfare economics is relevant only to those who hold to viewpoint A, and therefore useful only for appraising different ways of organising a system from that standpoint.

Background: Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. Methods: P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss' Kappa. Results: A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). Conclusion: The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes.

This chapter deals the nature of the economic approach to the production of health and healthcare (an activity which hopefully contributes to the health of patients, and always contributes to the income of providers!). It addresses the issue of why health economics and the creation of economics-based medicine grows in influence slowly but inexorably, continually opposed by Luddites and commercial interests who feel, sometimes totally erroneously, threatened by the wisdom of the health economics tribe! The objective of investment in healthcare is to produce health, although you would never guess this from the way practitioners and managers fail to evaluate changes in the health status of individual patients and the population! These folk typically organise their lives and their careers around issues of spending (inputs) and processes (activity in terms of patients treated and waiting times targets). Health economics, both as a subdiscipline, and as an influence on health and healthcare policy, has grown slowly over three decades.

The National Health Service (NHS) and local government-funded social care services are being challenged financially like never before. Real expenditure on the NHS has increased by less than 1% a year since 2010, and from 2018 there is no planned increase at all. In the face of everincreasing demand, care quality is unavoidably being eroded. In an attempt to hide extensive failures to meet them, waiting time targets for elective surgery and emergency care are being ‘reset’ with more flexibility. Patient discharges are increasingly being delayed by declining social care provision. How can we explain the government’s persistent reluctance to address funding shortages, and are policy responses likely to sustain patient care? Government is defending their ideologically driven response to ‘austerity’ by ensuring a stalemate with regard to NHS and social care funding. The purpose of this negative approach is to achieve a smaller state. Public expenditure as a percentage of GDP has been reduced from 45% in 2010 to 40% in 2016. Some in Government wish to push this percentage even lower if this means the privatisation of NHS funding. Public servants in NHS England are trying to break this deadlock and reduce pressures on patients and their carers. They are confronted by significant swings to the political right across Europe and elsewhere. They see the expenditure reductions in defence, the police and prisons as undermining the quality of public life just as the underfunding of the NHS is damaging the health of patients. The political ‘game’ of shrinking the size of the State is a fascinating struggle to determine the fate of valuable and vulnerable elements of the embattled welfare state as well as the overall quality of civil society.

Like many countries, the health care industries of England 1 and the United States consume large amounts of resources and struggle to achieve equity and efficiency. They attempt to reach these goals in quite different ways, exhibiting common challenges familiar to reformers throughout the world. Recent activities in England and the United States suggest that significant changes being discussed in the United States or implemented in the United Kingdom could upset previously accepted policies and threaten some or many of the gains made to provide more equal and timely accessible care to all individuals. Policy makers in both countries wrestle with similar problems of redistribution and system design. Although in the United States, the issues of equity and expenditure controls do not have the same importance as in England, both countries seek the “Holy Grail” of limiting spending both by government and the private sector by redesigning institutions that manifest inefficiency and contribute to inflationary pressures. Yet competing value systems permeate the political debate about how to accomplish these aims. These value systems underlie political preferences for regulation and markets. Although a minority in the United States advocates for universal care funded by a single payer, private employer-based insurance remains the bedrock mechanism. Unlike the United Kingdom and most Organisation for Economic Cooperation and Development (OECD) countries, the United States has never shown a political willingness to have government responsible for financial protection for all inhabitants against the cost of medical care. The United States has, however, accepted this responsibility for major components of society, namely, the aged, disabled, and low-income families and children (e.g., via Medicare, Medicaid, and the State Children's Health Insurance Program). This commitment was expanded with the Affordable Care Act (ACA) in 2010, commonly known as Obamacare. The outcomes of the two health care systems reflect a preference for collectivism in funding and access in the United Kingdom and for pluralism in funding (less third-party coverage) and a greater role for privately delivered care in the United States. But the battle continues in both countries as important groups advocate for the reversal of these preferences. Policy makers continually try to change their health care systems. Some of these changes seek to develop greater efficiency in how care is delivered as a means of controlling the burdens imposed on society by ever-increasing public and private expenditure. Both countries face common problems that have been well identified for decades but have proven difficult to resolve. Reformers face three common problems. First, unwarranted variations in clinical practice (Wennberg, 2008, Wennberg, 2012) are produced by price variations in insurance systems and volume variations elsewhere (Institute of Medicine, 2013). Second, both systems have been slow to develop measures of the value of health care outcomes, that is, improvements in the length and quality of life. Third, both health care systems have perverse incentives that inhibit efficiency-inducing change; for example, they use hospital pricing or tariff systems that incentivise activity with little regard to patient value. Inadequate evaluation and political resistance to change continue to produce inefficiency. The end result is unnecessary spending and unethical deprivation of beneficial care for some populations. The English single payer system is characterised by frugality and cycles of famine and plenty, with attendant bouts of supply side reform (Street & Maynard, 2007). Constrained funding in the 1980s led to the Thatcher reforms and the creation of the “quasimarket” of purchaser and providers contracting for public and private care. These structural reforms received increased funding in the early 1990s. By the end of the 1990s, financial parsimony was creating renewed performance problems, for example, increased waiting times for elective surgery. As a consequence, the Blair government financed a large increase in funding. Since 2010, the Coalition and now Conservative government has exerted extreme expenditure controls, and current plans will result in real per capita funding falling by 2018. Since the Thatcher era, the often violent fluctuations in NHS funding have been accompanied by the “redisorganisation” of structures and processes of care whilst maintaining universal cover age free at the point of use. The purchaser side of the National Health Service (NHS) market has evolved from health authorities to primary care trusts and now to clinical commissioning groups, all with similar functions and uncertain impact. The provider side of the market remains dominated by public institutions as private providers have made only marginal inroads to public funding. The current chronic underfunding of the NHS and social care, manifested currently by increased waiting times for elective procedures, has produced inevitable pursuit of the “Holy Grail” of increased productivity. The Five Year Forward View (NHS, 2014) involved the acceptance of government parsimony and for the 2015–2020 period. Its authors argued that the NHS would require £30 billion to meet demographic and technological demands, of which only £8 billion was to be provided from tax revenues. The additional £22 billion was to be funded from productivity increases. Current NHS spending is £110 billion. Currently, a frenzy of structural reform proposals range from integration of currently fragmented hospital, primary and social care systems to hospital mergers to the abolition of the purchaser-provider “market” with the creation of accountable care organisations. These proposals involve unevidenced merger plans and deskilling of nursing and other workforce changes. The Sustainability and Transformation Plans (https://www.england.nhs.uk/stps/) are radical but unlikely to yield £22 billion of productivity gains in 5 years. There is little available funding to finance the change process, and its duration is likely to take many years to free up resources. Both options assume that healthcare is much more expensive in the United States than in any OECD country because American patients use too much medical care. Yet the evidence does not support this assumption. Americans are less likely to be admitted to a hospital and have a lower length of stay once in a hospital than many OECD countries. Americans also are less likely to see a doctor or use fewer pharmaceuticals than patients in OECD countries. U.S. patients do use more very expensive medical devices such as MRIs or new and expensive drugs, but on net, the pluses and minus may cancel out. What separates United States spending from that in OECD countries are the prices charged for all medical activities. The reasons for the higher prices are complicated and due to a myriad of factors including the higher wages paid to most participants in the healthcare system (not only physicians); the much higher prices Americans pay for drugs and medical devices; and the fact that the complexity of the U.S. system has evolved in a way that requires the use of many more lawyers, consultants, and administrators, all of whom are well paid. The latter consideration is possibly more central because some key providers such as primary care physicians receive relatively low compensation relative to education costs and work conditions. Additional efforts within the United States that are sometimes related to the ACA include a broad interest in insurance redesign, emphasis on value from services provided, and a focus on patient-centred outcomes. Value-based cost-sharing approaches are being implemented in the United States as well as other OECD countries (Thomson, Schang, & Chernew, 2013), though these approaches are more easily implemented for certain services such as pharmaceuticals. The Medicare program is testing a number of value-based payment innovations and incentive payments. The Patient-Centered Outcomes Research Institute is a nongovernmental institute created under ACA that was charged with assessing the effectiveness and appropriateness of medical treatments. However, the Patient-Centered Outcomes Research Institute is not able to mandate coverage or reimbursement for any treatments and infamously is prohibited from considering cost per quality-adjusted life years in its recommendations despite widespread interest in this measure in many other countries. The American and the English health and social care systems differ greatly, but they are surprisingly similar in some dimensions. Key differences pertain to who pays for care and how it is delivered, with the United States having a more decentralized and fragmented system leading to inequalities in the provision of care and its funding. The English system is universal and largely free at the point of consumption system but constrained by limited funding (which also generates inequalities in access to timely care). The supply side problems are more similar for both countries. Increasingly, U.S. reform in terms of payment mechanisms is being emulated by the English. Both systems seek better measurement and management of “value,” that is, the effects of health care on the length and quality of patients' lives. The hospital systems of both countries are attempting to integrate care function and move away from “fee for service” to bundled or incentive payments. The American system is the product of producer incentives producing grossly inflated costs. Concomitantly, a growing proportion of the U.S. population has a limited view about who should be eligible for government-supported health care services and the types of services that should be supported. Despite greater underlying consensus in favour of universal coverage, the English system's crisis is a product of parsimony and fragmentation of funding and provision. Both systems are permeated by organisational inertia and the defence of political values and self-interest. The United States is grappling with more than a sea change given political restructuring and the very uncertain future of most expansions of insurance or medical cost coverage under the ACA. England faces potentially revolutionary structural changes in supply and a real political challenge in its single payment system. Although current trends are not positive, the authors maintain hope that both countries will prevent further deterioration in health care coverage and return towards more progressive policies to protect their inhabitants' access to care when subjected to the misfortunes of medical illness.

This interesting experiment is not likely to have been worth it, thinks Alan Maynard. But Michael Dixon says that if properly funded and released of red tape the internal market could increase accountability

Smallwood and Wrigley discuss whether private insurance should be used to fund the NHS.1 Healthcare in France is funded primarily by social insurance. The costs of care are fully reimbursed for serious conditions and to …

OBJECTIVE:To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery.DATA SOURCE:Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients).DESIGN:Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold.FINDINGS:The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0-6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8-2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year.CONCLUSIONS:There is a clear relationship between hospital CABG volume and mortality in Europe, implying a "safe" threshold volume of 415 cases per year.

Objective To review international policies to control expenditure on pharmaceuticals by influencing the behaviour of patients and providers and regulating the pharmaceutical industry. Method Systematic review of experimental and quasi-experimental studies. Published studies were identified with an electronic search strategy using MEDLINE and EMBASE from 1980 to May 2012. Studies were eligible if they assessed the effect of policies aimed at influencing the behaviour of patients and providers, and regulating the pharmaceutical industry. Outcome measures included pharmaceutical expenditure, prices or utilization; other resource use relating to pharmaceuticals; and health outcomes and patients’ or providers’ behaviour relating to pharmaceutical use. Quality assessment criteria for each study design were developed based on the standard criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. The review includes studies based on randomized controlled trials and rigorous quasi-experimental designs (interrupted time-series and controlled before-and-after studies). Studies were excluded if they were conducted within a single hospital or practice; related to pharmaceutical care services or disease management; had less than 6 months of follow-up period (or less than 12 months overall for interrupted time series); if data in controlled before-and-after studies were not collected contemporaneously or if no rationale was stated for the choice of control group; or if relevant and interpretable data were not presented. Results A total of 255 studies met the inclusion criteria for this review. The majority of the studies relating to patients evaluated cost sharing interventions such as user charges (52 studies). User charges do reduce utilization of pharmaceuticals, and reduce public expenditure by shifting costs to patients. But they reduce the use of essential as well as non-essential drugs, and without adequate exemptions they affect vulnerable groups disproportionately. The majority of studies relating to doctors evaluated the effects of educational approaches (78 studies), reimbursement restrictions (48 studies) and incentive systems (22 studies). Evidence on these policies is of mixed quality. It appears possible to influence prescribing modestly, through various means, but it is essential that messages to prescribers are based on good evidence of effectiveness and cost-effectiveness. Twenty-nine studies related to industry regulation, and they were of mixed quality. Evidence from studies of reference pricing suggests that this may result in cost savings. These are, however, achieved not by companies reducing or restraining prices, or by reductions in the overall volume of prescriptions, but by some shifts in use and shifting costs to patients, with consequent adverse effects on the equity of access to medicines. Other price and profit controls remain almost completely lacking in evaluative evidence. Conclusions It may be that the undesirable consequences of policies influencing patients, particularly user charges, can outweigh the benefits. To influence demand for pharmaceuticals, it is more appropriate to influence prescribing doctors and although interventions to improve prescribing practice have been developed, they often achieve relatively modest benefits and sometimes at high cost. Good evaluative evidence related to industry regulation is scarce despite its policy importance.

European Union (EU) healthcare systems, whether they are National Health Services or Social Insurance systems, are going through difficult times. Governments, the healthcare community and the public are increasingly concerned about the growth of health spending and the sustainability of their healthcare systems. The current economic crisis—the most intense, comprehensive and long lasting in post-war Europe—with its corollary of tax revenue falling, increased social needs and financial failure of the States, has contributed decisively to accentuate this concern, and placed health spending (along other items of social spending) as a critical aspect of the policies to control public sector deficits. While some of the contemporary concerns are directly related to the current economic crisis the recession has exerabated pre-existing problems. The pressures on all healthcare systems are familiar but resistant to resolution. First, there have been changes in morbidity patterns with the emergence of chronicity and multi-morbidities as the main drivers of healthcare utilization in developed countries. Disease is now evolving into a continuum of exacerbations and relapses leading to long-term functional impairment. These new morbidity patterns require changes in existing organizational structures and the integration of fragmented healthcare delivery systems. Unfortunately an evidence base to facilitate such innovation is absent. Second, the acceleration of technological change (in preventive, diagnostic, therapeutic, surgical, biological, imaging and other technologies), with a very rapid incorporation of new drugs, tests and devices into routine clinical practice has fuelled expenditure inflation. These new technologies sometimes involve significant clinical innovations (although not always cost-effectively) and, in other cases, the ‘innovation’ is limited to increased in prices (rather than to improved clinical outcomes). The combination of new drugs and technologies …

If I ruled the NHS I would buy stocks and an ample supply of rotten eggs. I would install one set of stocks outside Richmond House (the Department of Health headquarters in London) and another outside Quarry House (NHS England’s headquarters in Leeds). Evidence free practitioners of NHS “re-disorganisations” and other faith based policies—health secretary Jeremy Hunt, his predecessor Andrew Lansley, and the previous Labour incumbents Andy Burnham and Alan Milburn—would be punished, as an example. Iain Chalmers, Ben Goldacre, and associated “evidence apostles” would be supplied with the eggs. Such public shaming could be avoided if interventions were appropriately piloted and accompanied by well designed evaluations of their cost effectiveness. …

INTRODUCTION:Women now outnumber men in British medical schools. This paper charts the history of women in medicine and provides current demographic trends. SOURCES OF DATA:A historical literature review and routinely collected data from Department of Health and the Health and Social Care Information Centre. AREAS OF AGREEMENT:Clear gender differences are apparent in working practices, including greater likelihood of working part time and specializing in certain areas of medicine. AREAS OF CONTROVERSY:The increasing need to increase activity among the existing medical workforce is timely amidst a changing workforce demographic. GROWING POINTS:Workforce planners, policymakers and Royal Colleges should continue to develop interventions that may reduce disparities in career choices, as well as considering ways to increase participation and activity. AREAS TIMELY FOR DEVELOPING RESEARCH:Further research is needed to explore the cost-effectiveness of existing and future interventions in this field.

Using mortality as a quality indicator for hospitals