Choice and Inequality in Public Service Access and Outcomes: The Case of Healthcare

上一届工党政府推出了两项政策，增加了英国患者在哪里接受医院治疗的选择。首先，全科医生被要求为他们的病人提供一个选择医院参加第一次门诊预约。第二，新开设的医院治疗NHS患者，但由私营公司所有。这给了NHS患者更多的医院选择。在现任政府的领导下，病人的选择将进一步增加。在其他公共服务方面也有增加选择的举措，例如通过引入免费学校来增加教育。这项研究议程将研究增加患者的选择是否导致在使用NHS资助的服务，因此，患者的结果不平等的变化。历届政府都提倡选择权，原因有二。首先，因为他们相信病人看重自己选择的能力。第二，因为选择会给NHS医院带来提高质量的压力，从而吸引病人。有证据表明，为病人提供选择确实提高了医院的平均质量。关于这些政策如何影响不同类型的人或新的私营医院的影响的文章要少得多。即使选择导致医院质量的平均改善，了解哪些人受到政策的影响仍然很重要。公平获得医疗保健是国民保健制度的一项基本原则。此外，如果某些医院，特别是私营医院，只治疗特定类型的病人，这可能会限制推动质量所需的竞争压力，并可能影响政策的成本效益。研究方案将侧重于三个主要问题。第一个问题是，一些病人群体是否比其他人更愿意接受选择政策。年轻和富有的病人是否更有可能使用新的私人治疗中心？在过去十年开展的行动数量增加中，一些团体是否获得了比预期更大的份额？使用NHS服务的不平等的任何变化对患者健康结果的不平等有什么影响？第二个问题是，在新的私营医院不经营的地方，如何选择医院治疗。我将集中在产妇护理或分娩的例子。由于许多女性有不止一个孩子，我还可以测试母亲在决定在哪里生孩子时是否会使用自己的经验。特别是，母亲在分娩期间的经历是否会影响她在随后怀孕期间的决定。由于母亲的年龄或体重等导致分娩困难的因素也可能影响未来的怀孕，因此我将只关注影响产妇护理质量的随机因素的影响。一个可能的例子是，分娩是否发生在周末，因为周末可能会有更少的支持人员。然后，我将比较母亲们对自己经历的反应和对公共信息的反应，比如当地妇产科公开的丑闻。最后一个问题是，未来或潜在的增加患者选择的政策如何影响患者在哪里接受治疗以及是否接受治疗的不平等。前两个研究问题将评估过去政策的影响，但不能预测未来。我将用一个病人行为的模型来说明替代政策的潜在影响。这可能有助于政策制定者在政策选择之间做出选择，或者对拟议改革的设计进行修改。所有项目都将使用NHS住院病人的记录，其中包括所有医院预计过夜的病人和所有在医院分娩的母亲的信息。第一个项目还将利用一年两次的调查，跟踪一组50岁以上的人。

The previous Labour government introduced two policies that increased the choice that patients in England have over where to receive hospital treatment. First, GPs were required to offer their patients a choice over which hospital to attend for a first outpatient appointment. Second, new hospitals opened that treat NHS patients but are owned by private companies. This gives NHS patients a greater number of hospitals to choose between. Under the current government, patient choice is set to increase yet further. There are also moves to increase choice in other public services, such as education with the introduction of Free Schools. This research agenda will examine whether increased patient choice has lead to a change in inequalities in the use of NHS-funded services and, consequently, patient outcomes. Successive governments have advocated choice for two reasons. First, because they believe that patients value the ability to choose for its own sake. Second, because choice can generate pressure for NHS hospitals to improve quality, so as to attract patients. There is evidence that offering patients a choice did indeed lead to improvements in average hospital quality. Much less has been written on how the policies affected different types of people or on the impact of the new privately owned hospitals. Even if choice leads to an average improvement in hospital quality, it is still important to understand who was affected by the policies. Equity in access to healthcare is a founding principle of the NHS. Moreover, if certain hospitals, particularly those that are privately owned, only treat particular types of patients, this may limit the competitive pressure needed to drive quality and could impact the cost-effectiveness of the policies. The research programme will focus on three main questions. The first is whether some patient groups have responded to the choice policies more than others. Are younger and richer patients more likely to use the new private treatment centres? Have some groups received a greater than expected share in the increase in the number of operations performed over the past decade? What are the implications of any change in the inequality in use of NHS services on inequalities in patient health outcomes?The second question is how choice operates for hospital treatments where the new privately owned hospitals do not operate. I will focus on the example of maternity care, or childbirth. As many women have more than one child, I can also test whether mothers use their own experiences when making decisions about where to give birth. In particular, whether a mother's experience during childbirth affects her decisions during subsequent pregnancies. Since some factors that make childbirth difficult, such as the mother's age or weight, might also affect future pregnancies, I will focus only on the impact of random factors that affect the quality of maternity care. One possible example is whether the birth occurred at the weekend, when there are likely to be fewer support staff. I will then compare the responses of mothers to their own experiences to their responses to public information, such as publicised scandals at local maternity units.The final question is how future or potential policies to increase patient choice could affect the inequalities in where and whether patients are treated. The first two research questions will assess the impacts of past policies, but cannot predict the future. I will use a model of patient behaviour to illustrate the potential effects of alternative policies. This may help policy-makers to choose between policy options or make changes to the design of proposed reforms.All the projects will use the NHS records on inpatients, which include information on all those patients that hospitals expected to stay overnight and all mothers who give birth in hospital. The first project will also make use of a biannual survey that follows a group of people aged 50 and over.