The impact of medical labour on variation in patient outcomes: evidence from English public hospitals

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Motivation: The provision of healthcare is highly labour intensive, requiring a multi-disciplinary workforce with many years of training. Quality of care provided to patients depends crucially on both the availability and quality of individual staff and how they work together in teams. The NHS is the largest employer in England, employing more than a million people at a cost of more than £50 billion in 2016 (Department of Health, 2017). But NHS pay review bodies and the UK National Audit Office have noted that evidence on the efficient allocation of existing workers is scarce and long-term workforce planning is lacking (NHS Pay Review Body, 2017; Review Body on Doctor's and Dentist's Remuneration, 2017; National Audit Office, 2016). Such evidence and planning are important in order to contain costs and ensure that patients receive the highest possible quality of care. Aims and methodology: Our proposed research will use econometric techniques and rich administrative data to identify the causal effects of the way in which the health care workforce is organised on healthcare use and patient outcomes. Our first project explores the determinants of variation in the quality and productivity of the most senior doctors (NHS consultants). It is becoming clear that there is wide variation across doctors in their patient outcomes, even within the same hospital. Some of this may be due to patient allocation across doctors, for example, giving the most experienced harder to treat patients. But this does not appear to be the only driver. Our research will seek to quantify this variation and to determine what factors associated with the doctors are associated with this variation. We will use large scale data in order to separate out the effect of the individual doctor and the hospitals in which they work by exploiting movement in doctors across hospitals during their careers. Our second and third projects examine team production. Teams are the dominant form of organisation of staff in healthcare and it is therefore important to understand the causal effects of changes to teams. Project two examines explores the impacts of anticipated and unanticipated disruptions to nursing teams on patient care and costs. To do so, we will exploit new data sources that provide detailed data on staff rotas across all wards in 5 hospitals, which can be linked to treatments and patient outcomes. Project three will explore the relationship between doctor seniority, productivity and patient outcomes by analysing a series of strikes by junior doctors in 2016 and 2017. These strikes changed the mix of staff treating patients, leading to a temporarily higher proportion of senior staff (NHS consultants) working in these teams. To conduct our research we will exploit several data sources, including rich administrative data from the Hospital Episode Statistics and newly available, highly granular, data from one large London NHS hospital group. Applications, benefits and impact: Our ultimate aim is to allow policymakers to better understand the role of the workforce in variation in productivity, hospital utilisation and patient outcomes. Our findings will provide information and tools that help policymakers improve the efficiency of the existing workforce, raise the quality of patient care, and inform future workforce planning. We will maximise impact by producing a range of outputs that communicate the results to multiple audiences. We will submit a series of academic articles to top economic journals. We will also produce a number of press-released non-technical reports, which summarise the key findings directed at journalists, policymakers and other non-academic users. In particular, we will target national policymakers, including the Department of Health and Social Care and Health Education England, and health care providers, such as individual Acute Trusts. We will also engage with health care workers and their representatives.