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

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.

The 6 main non-academic groups will benefit from my research agenda are as follows:
1.Policy-makers within government
This group includes government and opposition politicians, and civil servants. The results of my research will demonstrate the distributional impact of past policies to increase choice, and simulate the effects of possible policy scenarios. All political parties in the UK claim that they seek to reduce health inequalities. Governments and opposition parties may therefore employ my research to help evaluate past reforms and plan future policy in both healthcare and other public services.
2.Healthcare market regulators
The healthcare market regulators in England include Monitor and the Cooperation and Competition Panel (CCP). I intend for Monitor to use the results from my research to fulfil its future role in promoting competition and safeguarding the continuity of services. For example, the degree of segmentation by patient type might affect Monitor's judgment on the degree to which providers compete, and whether the premium paid to private providers is justified by higher start up costs. The CCP could invoke my findings when deciding on mergers between healthcare providers.
3.Individuals and bodies that implement healthcare policy
This group is comprised of healthcare workers, managers and civil servants, including GPs, NHS hospital managers, the new clinical commissioning groups and NHS Commissioning Board, and the Department of Health. For example, the NHS Commissioning Board state that they will seek to "improve outcomes and guarantee no community is left behind or disadvantaged" (NHSCB, 2012). I intend that results of my research will demonstrate how the implementation of policy can affect the distributional impact of a particular reform. These groups may use this evidence to evaluate the effectiveness of previous implementation strategies or to inform the design of future implementation. For example, my findings may indicate that commissioners need to devote more resources to encouraging and supporting choice amongst disadvantaged patients.
4.Patient advocates
Patient advocates include charities, such as the Patients' Association and Age UK, and MPs. These groups will use my findings in 2 ways. First, to help lobby government on behalf of those they represent. Examples may include a charity requesting more financial and logistical support to help facilitate choice, or an MP campaigning for or against a particular healthcare provider closing, opening or merging within their constituency. Second, to provide direct support and advice to those they represent. Charities may wish to launch information campaigns or support groups; MPs might provide advice to their constituents.
5.Private healthcare providers
Any observed variation in the willingness or ability of patients to choose private providers could be affected both by the preferences of those providers, or the behaviour of NHS commissioners. Private providers may benefit from widening access and lobby commissioners to recommend their services to patients. Alternatively, new entrants might use my results to calculate an expected rate of return from opening a new centre. It is the job of Monitor to ensure that the behaviour of private providers is of benefit to patients.
6.Patients and their families
Patients will benefit directly through a greater awareness that they have the right to choose. They benefit indirectly from any improvements in the content and implementation of healthcare policy.
Whilst the primary beneficiaries in each group will be those in the UK, I believe there is potential for substantive international impact. There are a number of countries with similar healthcare systems, such as Sweden and Denmark, where it would be possible to draw direct comparisons. For other countries, there is an interest in comparing how alternative systems operate and how patients behave when faced with common features, such as new providers.