John Posnett

The determinants and effects of health expenditure in developed countries

Previous studies of international differences in health spending have been restricted to the use of relatively small samples of cross-sectional data. Our objective here is to re-examine the results of previous work using a sample of 560 pooled time-series and cross-section observations. Results confirm the importance of GDP as a determinant of health spending, with an estimated income elasticity at or around unity, but also suggest that OECD countries should not be regarded as a single, homogeneous group. The importance of some non-income variables is also confirmed, although the direct effect of these factors appears to be small.

An economic approach to clinical trial design and research priority-setting

Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.

Charity donations in the UK: New evidence based on panel data

Abstract This paper presents a set of panel data estimates for 159 of the most prominent UK charities for the period 1983–1990. In evaluating alternative specifications, we settle on a fixed-effects estimation. Social welfare charities are shown to fund raise short of the point at which net revenues are maximized, whereas health and overseas charities are found to net revenue maximize. Religious charities maximize total revenues. Estimates of price and fund-raising elasticities are presented for charities overall and for four cohorts. For alternative income sources, no evidence of crowding-out is found.

Demand for charity donations in private non-profit markets: The case of the U.K.

Abstract This paper presents estimates of the demand for donations for U.K. charities in 1985. These estimates make demand depend upon price, fund-raising expenditure, a quality index, and alternative revenue sources. The price elasticity of donations found here shows, for the most part, an elastic response and is consistent with previous studies using U.S. data. Our empirical results suggest that non-profits in the U.K., unlike their counterparts in the U.S., are net revenue maximisers . We discovered no significant evidence that public donations crowded out private donations in our sample of 300 charities.

Team approach versus ad hoc health services for young people with physical disabilities: a retrospective cohort study

BACKGROUND Young people with physical disabilities often have difficulty attaining independence in adult life and consequently need lifelong support from parents and from health-care and social-care services. There are concerns about the organisation and cost-effectiveness of such services and their ability to meet the independence training and serious health needs of these young people. Our aim was to compare a young adult team (YAT) approach with the ad hoc service approach in four locations in England, in terms of their ability to enhance the participation in society of these young people and their cost. METHODS We did a retrospective cohort study, in which we interviewed 254 physically disabled young people. 124 healthy controls were given a questionnaire. We interviewed with standardised measures and used logistic regression analysis to test for effects of ad hoc and YAT services. The Mantel-Haenszel chi2 statistic was used to test for differences in resource use between areas in which the YAT and ad hoc services were available. FINDINGS The absence of pain, fatigue, and stress increased the odds of participation two-fold to four-fold. After adjustment for these factors, young people cared for by multidisciplinary YAT teams were 2.54 times (95% CI 1.30-4.98) more likely than those who used ad hoc services to participate in society. Resource use did not differ between the two service types. INTERPRETATION A YAT approach costs no more to implement than an ad hoc approach, and is more likely to enhance participation in society of young people with physical disabilities.

Charitable donations by UK households: evidence from the Family Expenditure Survey

This paper reports estimates based on both standard Tobit and generalized Tobit techniques of the determinants of charitable giving in the UK using 1984 Family Expenditure Survey data. This is the first such study using UK data. Separate estimates are presented of the determinants of participation and of the level of donations by giving households. Participation is seen to be sensitive to income, the tax-price of giving, and a range of demographic variables, while the level of donations varies primarily with income. Donations are found to be inelastic with respect to changes in disposable income.

Joint Supply and the Finance of Charitable Activity

This article puts forth a joint-supply model of charity, in which the purchase of a private good yields excess revenues used to finance a public charitable output. Joint supply is an especially effective fund-raising technique when the private and public goods are Hicksian complements. Competitive advantages, gained through tax-exempt status, also allow charities to outcompete for-profit competitors. Evidence drawn from U. K. charities demonstrates that large successful charities generate a sizable portion of revenues from direct-trading activities.

Free riding and uncertainty

This paper examines the effects of uncertainty on pure public good provision and free-riding behavior. Two models are presented. In the first, Nash behavior is assumed and uncertainty is with respect to the contributions of the rest of the community. For the second model, non-Nash behavior is assumed and uncertainty concerns the nonzero response that a representative individuals optimizing choice will cause in the community. Propositions provide sufficient conditions for increased risk to worsen free-riding behavior in the two models. For Nash behavior, we also give the sufficient condition for increased risk to ameliorate free-riding behavior. The effects of group size on free riding are also explored for uncertain responses by the community.

The Private Provision of Public Goods: a Perspective on Neutrality

This article has two purposes. First, the bounds of the neutrality theorem for the private provision of public goods are more firmly established The focus is on the non-neutrality of non-Nash equilibria in which nonzero conjectures depend on the agents own contribution. The non-neutrality of equilibria involving general externalities, nonlinear constraints, and joint products are also examined Second, it is argued that non-Nash behavior and joint products, induced by institutional design, may be behind the contribution patterns reported by some researchers who investigate charities.

Volume of clinical activity in hospitals and healthcare outcomes, costs, and patient access.

Background Concentration of the provision of hospital services is sometimes seen as a way to reduce costs and improve the quality and efficiency of care. This paper, based on an issue of Effective Health Care Vol 2, No 8 summarises the results of systematic reviews carried out at the University of York to assess research into the possible relation between volume of clinical activity in hospitals and the outcomes of quality of health care, hospital costs (economies of scale), and patient access. Full reports of the methods used and the results of these reviews, including details of the studies included, are available from the National Health Service (NHS) Centre for Reviews and Dissemination and cannot be presented here due to lack of space. d