Alan Maynard

Early appraisal of China's huge and complex health-care reforms

Chinas 3 year, CN¥850 billion (US

Nurse staffing and healthcare outcomes: a systematic review of the international research evidence

125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The governments undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.

Evidence-based medicine: an incomplete method for informing treatment choices

The relationship between quality of care and the cost of the nursing workforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twenty-two large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.

The Cost of Diabetes

7The effective use of such resources requires a major change in the speed with which clinical and non-clinical managers translate new evidence into clinical practice. To be successful, the Cochrane Collaboration has to facilitate the translation of new evidence into changed clinical behaviour and better services for patients. The advocacy role of proponents of evidence-based medicine and the Cochrane Collaboration’s recommendations for effective professional behaviour

DEVELOPING THE HEALTH CARE MARKET

This paper estimates the cost of diabetes in England and Wales in 1984 to be in excess of £259.5 million. The costing methodology used follows the ‘cost of illness’ framework. This framework defines three elements for costing: direct, indirect and psychological, although the latter element is left out of the calculation because monetary valuations for this element have never been adequately estimated. Direct costs include resources used to prevent, detect, and treat diabetes. Indirect costs relate to the loss of productive output caused by absenteeism, early retirement, and premature mortality. The estimate which has been obtained is likely to be an underestimate because of the weaknesses and gaps in the data sets. The estimate of the total lost earnings from diabetes varied greatly according to the choice of absentee rate. If there was no significant difference between absenteeism in the diabetic community and the non‐diabetic community then the cost of diabetes would be £259.5 million. If on the other hand the diabetic community was prone to three times as much absenteeism as the non‐diabetic community then the cost of diabetes would rise to £602.5 million. The costs of diabetes as a subsidiary diagnosis are extremely difficult to identify. They have been estimated in this study to be £86 million but this is thought to be an overestimate. Nevertheless the cost of diabetes is significant and thus the search for more efficient treatment regimens may reduce such costs as well as enhance the quality of life of the patients concerned. Important policy conclusions to be drawn from this analysis are to improve the epidemiological underpinning upon which such estimates are based and to increase the use of economic evaluation, rather than ‘cost of illness’ methodology, to assist in priority‐setting in health care.

Skill mix changes: substitution or service development?

The structure of health care services varies enormously from country to country and the responses of policy makers to these difficulties exhibit similar characteristics. There are a number of features of health care systems which make monitoring outcomes and policy formulation especially problematic poor data on outcomes and perverse incentives facing agents are good examples. In the UK, resource allocation has been effected within the National Health System, a public health care system par excellence. Recently, however a number of reforms have been effected which have increased the role of quasi markets there has been an attempt to enhance market contestability in health care provision by formalising relationships between buyers and sellers. This article investigates and evaluates the reforms which have occurred. Section 2 examines the characteristics of the health care market and Section 3 identifies the objectives of the health care system. Section 4 discusses the attempts to create a health care market and Section 5 ends with some concluding comments.

Activity based financing in England: the need for continual refinement of payment by results

An extensive review of published studies where doctors were replaced by other health professions demonstrates considerable scope for alterations in skill mix. However, the studies reported are often dated and have design deficiencies. In health services world-wide there is a policy focus which emphasises the substitution of nurses in particular for doctors. However, this substitution may not be real and increased roles for non-physician personnel may result in service development/enhancement rather than labour substitution. Further study of skill mix changes and whether non-physician personnel are being used as substitutes or complements for doctors is required urgently.

Challenges for the National Institute for Clinical Excellence

The English National Health Service is introducing activity based tariff systems or Payment by Results (PbR) as the basis for hospital funding. The funding arrangements provide incentives for increasing activity, particularly day surgery, and, uniquely, are based on costing data from all hospitals. But prices should not be based on average costs and the potential of PbR to improve the quality of care is yet to be exploited. Without refinement, PbR threatens to undermine expenditure control, to divert resources away from primary care, and to distort needs based funding.

Advances in health economics

So far NICE has focused on evaluating new technologies rather than existing ones. But this approach is creating inflationary pressure that the NHS cannot afford

Lessons from international experience in controlling pharmaceutical expenditure. III: Regulating industry.

List of Contributors. About the Authors. Preface. Workshop Participants. Acknowledgements. Willingness to Pay for Health Care (C. Donaldson and P. Shackley). Using Discrete Choice Experiments in Health Economics: Moving Forward (M. Ryan and K. Gerard). Methods for Eliciting Time Preferences Over Future Health Events (M. van der Pol and J. Cairns). Economic Evaluation for Decision making (A. Gray and L. Vale). Incentives in Health Care (A. Scott and S. Farrar). The Nursing Labour Market (R. Elliott, et al.). The Economics of the Hospital: Issues of Asymmetry and Uncertainty as they Affect Hospital Reimbursement (A. McGuire and D. Hughes). Measuring Efficiency in Dental Care (D. Parkin and N. Devlin). Ageing, Disability and Long term Care Expenditures (P. McNamee and S. Stearns). Economic Challenges in Primary Care (A. Maynard and A. Scott). Equity in Health Care: The Need for a New Economics Paradigm? (G. Mooney and E. Russell). Economics of Health and Health Improvement (A. Ludbrook and D. Cohen). Index.