John Buckell

Efficiency, heterogeneity and cost function analysis: empirical evidence from pathology services in the National Health Service in England

Pathology services are increasingly recognized as key to effective healthcare delivery – underpinning diagnosis, long-term disease management and research. To the extent that pathology services affect a patient’s treatment pathway, significant healthcare costs are influenced directly by the performance of these services. Given pressures on the UK Department of Health to make efficiency savings and that little is known about the efficiency of pathology laboratories, this area offers unlocked potential for efficiency gains. We adopt a time varying inefficiency model, with laboratory-specific time paths for inefficiency, to identify potential savings in pathology services based on a panel of 57 English laboratories over a 5 year period. We apply a range of approaches to account for observable and unobservable heterogeneity between laboratories. We find potential efficiency savings of 13% in pathology services in this sample, which implies the potential for an annual saving of £390m in pathology across the NHS. Our study also provides valuable insights into the impact of a range of factors influencing laboratory costs.

Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment

Objectives To provide the policy-relevant estimates of impacts of alternative flavour bans on preferences and demand for cigarettes and e-cigarettes in adult smokers and recent quitters. Methods A best–best discrete choice experiment (DCE) is used to elicit smokers’ and recent quitters’ preferences for flavours, price, health impact and nicotine level in cigarettes and e-cigarettes. Choice of tobacco products and an opt-out option were examined. An efficient design yielded 36 choice sets. Exploded logit choice models were estimated. Flavour bans are modelled by restricting flavour coefficients in the estimated model. Setting and participants A sample of 2031 adult smokers and recent quitters was recruited to complete an online survey and DCE. Results Current smokers and recent quitters, on average, prefer cigarettes and menthol cigarettes over flavoured e-cigarettes. However, there is substantial preference heterogeneity by younger adults (ages 18–25), race/ethnicity and respondents with higher education. Our predictions suggest that a ban on menthol cigarettes would produce the greatest reduction in the choice of cigarettes (−5.2%), but with an accompanying increase in e-cigarettes use (3.8%). In contrast, banning flavours in e-cigarettes, while allowing menthol in cigarettes would result in the greatest increase in the selection of cigarettes (8.3%), and a decline in the use of e-cigarettes (−11.1%). A ban on all flavours, but tobacco in both products would increase ‘opting-out’ the most (5.2%) but would also increase choice of cigarettes (2.7%) and decrease choice of e-cigarettes (−7.9%). Conclusions A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would likely be more effective in reducing the choice of cigarettes. A ban on all flavours in both products would likely reduce the smoking/vaping rates, but the use of cigarettes would be higher than in the status quo. Policy-makers should use these results to guide the choice of flavour bans in light of their stance on the potential health impacts both products.

Hierarchical Performance and Unobservable Heterogeneity in Health: A Dual-Level Efficiency Approach Applied to NHS Pathology in England

Understanding the source of inefficiency within health system organisational structures is a key aspect of performance measurement and management; and is of increasing importance to policy makers. This study uses a unique panel dataset to study the efficiency performance of pathology services in the National Health Service (NHS) in England for the first time. We apply a dual-level stochastic frontier (DLSF) model (J Prod Anal 37(1):1–27, 2012) to isolate the source of inefficiency at two vertically distinct organisational levels: an upper level of Strategic Health Authorities (SHAs); and a lower level of laboratories grouped within SHAs. Wedevelop the DLSF framework—in line with recent developments in the wider panel data literature—to control for the influence unobserved heterogeneity, which is a key issue for healthcare performance analysis. We find statistically significant variation in inefficiency performance at both organisational levels in pathology services. Weuse these measures to compute overall inefficiency for NHS pathology services, and corresponding savings estimates. Finally we comment on the wider modelling implications of our research with respect to the separation of inefficiency and unobserved heterogeneity when applied to multi-level data structures.