The impact of medical labour on variation in patient outcomes: evidence from English public hospitals
Lead Research Organisation:
Institute for Fiscal Studies
Department Name: IFS Research Team
Abstract
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.
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.
Planned Impact
We intend to contribute to four groups in society (i) public policy makers, (ii) organisations delivering healthcare, (iii) health care workers, and (iv) the recipients of healthcare services.
1) Public policy makers
Serious shortcomings in the management of short-run demand for staff and in future planning have been noted by the National Audit Office and NHS pay review bodies (NHS Pay Review Body, 2017; Review Body on Doctor's and Dentist's Remuneration, 2017; National Audit Office, 2016). The recently published draft health and care workforce strategy for England to 2027 notes that prior planning had been limited to just five years ahead and that the previous focus on increased recruitment had come at the expense of developing existing staff (Health Education England, 2017). There is now increased awareness of these deficiencies, heightened by Brexit and the potentially large reductions in labour supply that may follow. This has stimulated interest in addressing long-standing staffing issues. The research in this proposal is intended to contribute to closing the knowledge gap. We aim our research as an input to policy aimed at (a) improving current and future workforce deployment (b) labour force cost containment and (c) improvements in the quality of healthcare.
2) Health care providers
While national policy makers can offer guidance and rules, many day to day and longer-term staffing decisions are made by healthcare providers. Most of the issues we address are common to all healthcare providers, including disruptions to nursing teams due to sickness or staff exits, the composition of multi-disciplinary teams and the variation in the quality of physicians.
We will provide evidence of two types to both national policymakers and providers. The first relates to particular policy questions, such as how junior doctor strikes affected patient care and the impact of employing agency nurses. Better understanding of these policies or events will aid providers in making efficient choices about their permanent and temporary workforce. The second type relates to more general questions on the consequences of particular models of workforce organisation. This will include, for example, the relationship between doctor seniority and patient outcomes, and the most effective ways to organise teams. Results may affect how providers roster staff, or the composition of the staff that they recruit.
3) Healthcare workers and their representatives
Our research focuses on the behaviour of healthcare workers and the impact of this on the patients they treat. While healthcare workers have in-depth knowledge about their patients, they typically do not have access to complex staffing data, and are unlikely to be able to extract lessons from the academic literature as readily as academic researchers and associated academics. We will interact with representative bodies of the medical workforce so they both input into, and benefit from, our work.
4) Health service users
The end users of the public services delivery we study are patients and their families. Our contribution to this group will primarily come indirectly by improving the policies of government and hospital providers, and communicating with national bodies representing staff. However, one of our objectives is to demonstrate the usefulness of administrative data in understanding variation in the quality of treatment. Our research can therefore be used to demonstrate to service users the benefits that can be delivered from research and the increased understanding gained from using health data. Thus we hope our research will also contribute to the very lively debate on privacy concerns in the use of administrative data and to demonstrate the benefits of appropriate and ethical use of personal data.
1) Public policy makers
Serious shortcomings in the management of short-run demand for staff and in future planning have been noted by the National Audit Office and NHS pay review bodies (NHS Pay Review Body, 2017; Review Body on Doctor's and Dentist's Remuneration, 2017; National Audit Office, 2016). The recently published draft health and care workforce strategy for England to 2027 notes that prior planning had been limited to just five years ahead and that the previous focus on increased recruitment had come at the expense of developing existing staff (Health Education England, 2017). There is now increased awareness of these deficiencies, heightened by Brexit and the potentially large reductions in labour supply that may follow. This has stimulated interest in addressing long-standing staffing issues. The research in this proposal is intended to contribute to closing the knowledge gap. We aim our research as an input to policy aimed at (a) improving current and future workforce deployment (b) labour force cost containment and (c) improvements in the quality of healthcare.
2) Health care providers
While national policy makers can offer guidance and rules, many day to day and longer-term staffing decisions are made by healthcare providers. Most of the issues we address are common to all healthcare providers, including disruptions to nursing teams due to sickness or staff exits, the composition of multi-disciplinary teams and the variation in the quality of physicians.
We will provide evidence of two types to both national policymakers and providers. The first relates to particular policy questions, such as how junior doctor strikes affected patient care and the impact of employing agency nurses. Better understanding of these policies or events will aid providers in making efficient choices about their permanent and temporary workforce. The second type relates to more general questions on the consequences of particular models of workforce organisation. This will include, for example, the relationship between doctor seniority and patient outcomes, and the most effective ways to organise teams. Results may affect how providers roster staff, or the composition of the staff that they recruit.
3) Healthcare workers and their representatives
Our research focuses on the behaviour of healthcare workers and the impact of this on the patients they treat. While healthcare workers have in-depth knowledge about their patients, they typically do not have access to complex staffing data, and are unlikely to be able to extract lessons from the academic literature as readily as academic researchers and associated academics. We will interact with representative bodies of the medical workforce so they both input into, and benefit from, our work.
4) Health service users
The end users of the public services delivery we study are patients and their families. Our contribution to this group will primarily come indirectly by improving the policies of government and hospital providers, and communicating with national bodies representing staff. However, one of our objectives is to demonstrate the usefulness of administrative data in understanding variation in the quality of treatment. Our research can therefore be used to demonstrate to service users the benefits that can be delivered from research and the increased understanding gained from using health data. Thus we hope our research will also contribute to the very lively debate on privacy concerns in the use of administrative data and to demonstrate the benefits of appropriate and ethical use of personal data.
Publications
Gravelle H
(2019)
Spatial competition and quality: Evidence from the English family doctor market
in Journal of Health Economics
Stoye G
(2023)
The effects of doctor strikes on patient outcomes: Evidence from the English NHS
in Journal of Economic Behavior & Organization
Zaranko B
(2023)
Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.
in BMJ quality & safety
| Description | The research funded through this grant has significantly enhanced our understanding of the role of individual staff and teams in providing healthcare to patients in the English NHS. Specifically, we used produced new knowledge on the roles of three distinct staff groups: • We quantified substantial variation in the quality of care (as measured by their causal impact on patient survival rates) provided by NHS cardiologists when treating heart attack patients. The performance of these consultants improve with experience, but these experience gains are small compared to the innate differences in effectiveness across staff. We also showed that significant improvements in patient survival rates can potentially be achieved by reassigning patients across the existing stock of cardiologists: our estimates show that cardiologists vary in their ability to treat 'low' and 'high' risk patients, and that reassigning particular patients to cardiologists (within the same hospital) on the basis of this comparative advantage could reduce heart attack mortality by almost 10 percent. This demonstrates that patient outcomes could be improved by reorganising the existing senior NHS workforce. • We examined the effect of team working in a hospital context. Human capital theory indicates different impact for general, firm and team specific capital in different settings. By exploiting a novel linkage between electronic staffing records and patient medical records, we are able to examine the impact of the size and composition of nursing teams at the daily level on an important marker of clinical quality: whether a patient under the care of the team dies dies during their hospital stay. Our research design allows us to control for ward specific factors that may be associated with patient acuity. We show that team specific capital improves patient outcomes and that there a returns to seniority within nursing. We also show non- linear effects of being short staffed, the importance of nurse managers and that, at the margin, using less skilled nurses and nurses who are not familiar with the ward or hospital does not prevent patient death. Our research demonstrates that substituting less for more skilled nurses will not address issues of staff shortages and that policy should not only seek to increase the number of nurses but also target investment in skill within the current labour force, retention of experienced nurses and leadership training. • Using novel data on NHS workforce, we show that the 2016 junior doctor strikes had substantial, negative impacts on particular groups of emergency patients treated during the strike. Measuring exposure to the strikes using the ratio of junior to senior doctors prior to the strikes, we show that older, and black and mixed ethnicity patients, and patients living in the most deprived quarter of areas, all experienced higher readmission rates during the strikes. This indicates that industrial action taken by medical staff (and specifically junior doctors) can have negative impacts on patient health. This is particularly important given the risk of future industrial action over working conditions and pay currently being discussed among NHS staff. • The project demonstrated the importance of three administrative datasets: the hospital episode statistics, Imperial NAME, and the Electronic Staff Record. The final two datasets were used by researchers for the first time to study the impacts of staff on patient outcomes, and is a powerful demonstration of the importance of using routinely collected administrative data to track and improve care standards. |
| Exploitation Route | First, our results demonstrate the importance of using administrative data to identify interventions that improve patient outcomes, and provides policymakers and practitioners with practical examples of how care outcomes could be improved. For example, we highlight that outcomes for heart attack patients could be improved without hiring additional staff but instead by reorganising existing staff. The results on team disruptions could also be used to guide better contingency planning for key staff absences. Building this evidence base is important in supporting and expanding the collection of such data. Second, the media may use the findings to inform the public about the importance of medical staff, and why the quality of care in the NHS may be variable. This will provide evidence for the public debate about how to improve NHS care, and over the size and the structure of the NHS workforce. Finally, this work has contributed to a topical and expanding body of literature on the role of the medical workforce in determining hospital productivity and patient outcomes. We hope that other researchers will build on this work, particularly in the UK, to further explore the mechanisms that underlie our results. |
| Sectors | Education Healthcare |
| Description | Our work on team production uses the electronic staff records from one large NHS hospital trust. We were able to show that routine data collected by the Trust can be used to improve patient outcomes. We also were able - at the request of the Trust - to explore what type of nursing shortage - and of what duration - impacted patient outcomes. We prepared two reports specifically for the Trust showing that there are 'tipping points'. These reports have been discussed with the Trust as input to their work on improving staffing and using routine data to help improve patient care. Our published research has also been used by the Royal College of Nurses as part of their policy recommendations for improving retention and recruitment in the nursing profession. A summary of our work on cardiologist quality was discussed with the Medical Director for Professional Leadership and Clinical Effectiveness at NHS England as part of ongoing dialogue about how to measure and improve consultant productivity. A summary of our work on junior doctor strikes was discussed with the Department of Health and Social Care Workforce Information and Analysis team. The work highlighted that while the strikes had no aggregate effect on patient outcomes, there were negative impacts on some ethnic minority groups. This indicates that both national policymakers and managers in trusts need to carefully respond short-term measures during staff shortages in order to avoid negative consequences for all patients. We also disseminated these results to hospital managers by writing an op-ed summarising the findings of the work in the Health Services Journal, also discussing why industrial action by doctors in 2023 (and in the future) may differ from the impacts of past strikes |
| Sector | Healthcare |
| Impact Types | Policy & public services |
| Description | Presentations to NHS Trust nursing directorate members of our research on nursing teams |
| Geographic Reach | Local/Municipal/Regional |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Description | Presentations to NHS Trust nursing directorate members of our research on nursing teams |
| Geographic Reach | Local/Municipal/Regional |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Description | Research cited in RCN report |
| Geographic Reach | National |
| Policy Influence Type | Citation in other policy documents |
| Description | American Economic Association/ASSA Annual Meeting 2023 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Team Composition and the Returns to Human Capital: Evidence from Nursing Teams |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://www.aeaweb.org/conference/ |
| Description | Essen Health Conference 2022, Essen University, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | Team Composition and the Returns to Human Capital: Evidence from Nursing Teams |
| Year(s) Of Engagement Activity | 2022 |
| Description | European Association of Labour Economists Annual Meeting, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Undergraduate students |
| Results and Impact | Team Composition and the Returns to Human Capital: Evidence from Nursing Teams |
| Year(s) Of Engagement Activity | 2022 |
| Description | European Health Economics Association Annual Conference, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Public/other audiences |
| Results and Impact | The distribution of doctor quality: evidence from cardiologists in England |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://euhea.eu/welcome_conference_2022.html |
| Description | European Health Economics Association Annual Conference, University of Oslo, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | Team Composition and the Returns to Human Capital: Evidence from Nursing Teams |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://euhea.eu/welcome_conference_2022.html |
| Description | Presenting a Seminar at University of Oxford, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Postgraduate students |
| Results and Impact | The distribution of doctor quality: evidence from cardiologists in England |
| Year(s) Of Engagement Activity | 2022 |
| URL | https://talks.ox.ac.uk/talks/id/ae55db4d-41e5-4f7e-aa8d-5c68ee781431/ |
| Description | Royal Economic Society, Virtual Conference, 2022 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | Team Composition and the Returns to Human Capital: Evidence from Nursing Teams |
| Year(s) Of Engagement Activity | 2022 |
| Description | The Effects of Doctor Strikes on Patient Outcomes: American European Health Economics Study Group |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Postgraduate students |
| Results and Impact | Presentation of paper at American European Health Economics Study Group conference in Barcelona July 2022 |
| Year(s) Of Engagement Activity | 2022 |
| Description | The Effects of Doctor Strikes on Patient Outcomes: EALE Presentation |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Presentation of our paper The Effects of Doctor Strikes on Patient Outcomes: Evidence from the English NHS at EALE 2022 in Padova |
| Year(s) Of Engagement Activity | 2022 |