Julian Le Grand

Quasi-markets and social policy

Introduction J.Le Grand & W.Bartlett - The Theory of Quasi-Markets W.Bartlett & J.Le Grand - Quasi-Markets, Contracts and Quality in Health and Social Care: The US Experience C.Propper - Quasi-Markets and the NHS Reforms L.Harrison & W.Bartlett - Quasi-Markets and the Reform of Community Care L.Hoyes & R.Means - Quasi-Markets and Educational Reforms W.Bartlett - The Quasi-Market in Social Housing G.Bramley - Quasi-Markets and Regulation C.Propper - Quasi-Markets and Social Policy: The Way Forward? J.Le Grand & W.Bartlett - References - Index

Inequalities in health: Some international comparisons

There have been many attempts to compare various dimensions of inequality between different countries, including, particularly, those relating to income and wealth. However, there have been relatively few international studies of inequalities in health.2 Given that, as has been noted by economists as eminent as Kenneth Arrow and Amartya Sen, 3 individuals’ states of health are contributors to welfare comparable in impact to income or wealth holdings, this relative poverty of health studies is surprising. It cannot be explained by lack of data. Such studies of health inequality as do exist generally concern mortality and the data situation here is significantly better than that for other welfare indicators, such as income. There are extensive data, available for a large number of countries; although the quality varies [see United Nations (1982)], it is likely to be generally higher than that for income data. Moreover, there are fewer methodological problems associated with the data; for obvious reasons, mortality is easier to define than income, and there is no problem equivalent to that of defining the income unit.

Social exclusion in Britain 1991—1995

The purpose of this paper is to offer a working definition of social exclusion and to operationalize it in such a way that an initial empirical analysis of social exclusion in Britain today can be undertaken. After a brief review of conceptions of social exclusion and some of the key controversies, we operationalize one definition based on the notion of participation in five types of activity—consumption, savings, production, political and social. Using the British Household Panel Survey, indicators for participation on these dimensions are developed and analysed both cross-sectionally and longitudinally for the period 1991–5. We find strong associations between an individual’s participation (or lack of it) on the five different dimensions, and on each dimension over time. However, there is no distinct group of socially excluded individuals: few are excluded on all dimensions in any one year and even fewer experience multiple exclusion for the whole period. The results support the view that treating different dimensions of exclusion separately is preferable to thinking about social exclusion in terms of one homogeneous group.

Knights, Knaves or Pawns? Human Behaviour and Social Policy

There are two fundamental changes currently under way in the welfare state. These are the development of quasi-markets in welfare provision, and the supplementation of ‘fiscal’ welfare by ‘legal’ welfare: policies that rely on redistributing income through regulation and other legal devices, instead of through the tax and social security system. This article argues that these changes are in part the result of a fundamental shift in policy-makers’ beliefs concerning human motivation and behaviour. People who finance, operate and use the welfare state are no longer assumed to be either public spirited altruists (knights) or passive recipients of state largesse (pawns); instead they are all considered to be in one way or another self-interested (knaves). However, since neither the ‘new’ nor the ‘old’ set of assumptions are based on evidence, policies based on the new set are as likely to fail as those based on the old. What is needed are ‘robust’ policies that are not dependent on any simple view of human behaviour.

Equity and choice : an essay in economics and applied philosophy

Some preliminaries equity versus efficiency - the elusive trade-off the measurement of changes in economic welfare methods of approach economic conceptions of equity equity and choice equity, health and health care equity and grants to local governments equity, the measurement of choice sets and income taxation.

The Theory of Quasi-Markets

As noted in Chapter 1, the majority of the quasi-market changes are only just being put into place, and it will not be feasible to assess their empirical consequences for several years. However, this does not mean that any kind of evaluation is impossible. It is possible to undertake a theoretical analysis that specifies the conditions quasi-markets will have to meet if they are to succeed, and then to make a preliminary empirical assessment of the extent to which those conditions appear to be met in practice. However, to do this requires development of the theory of quasi-markets; and such is the aim of this chapter.

The Theory of Government Failure

This article outlines a theory of government failure that parallels the more well-established theory of market failure. It builds on the work of the public choice school concerning the behaviour of governments under the assumption that all relevant agents pursue their selfinterest. It examines the theoretical consequences for efficiency and equity of three kinds of government activity: provision, subsidy and regulation. The conclusion is reached that all three may create inefficiency and inequity, but that the form and magnitude of the failure will differ with the type of activity; hence it is important that the three are distinguished. It is also emphasised that the extent of government failure in each case (and whether it is greater or smaller than the corresponding areas of market failure) is ultimately an empirical question, not a theoretical one.

Equity and Choice.

SACOG is required by law to conduct an environmental justice and Title VI analysis as part of the MTP/SCS, to determine whether the MTP/SCS benefits low-income and minority communities equitably, whether the Plan’s transportation investments have any disproportionate negative effects on minority and/or low-income populations in the SACOG region, and whether the plan has disparate impacts on the basis of race, color, or national origin. These environmental justice areas will be referred to throughout this chapter as Low Income High Minority (LIHM) Areas. While Chapter 5 analyzes the general performance of the MTP/SCS, this chapter provides SACOG’s environmental justice and Title VI analysis. The chapter seeks not only to fulfill SACOG’s legal requirements to analyze environmental justice and Title VI impacts of the MTP/ SCS, including expanded performance measures from previous MTPs, but also to understand and compare the benefits and effects of the MTP/SCS for the region’s residents, including those who live in more low-income or minority communities. The chapter includes the following: • Legal and regulatory requirements for environmental justice analysis • How Low Income/High Minority (LIHM) Areas are defined for SACOG’s analysis • Characteristics of LIHM Areas • Analysis of LIHM Area impacts of the MTP/SC • FTA guidance and findings for Title VI analysis • Plan implementation efforts and strategies for enhancing analytical capacity and expertise. Legal and Regulatory Framework

Ethnicity, equity and the use of health services in the British NHS

This paper addresses the extent to which equity of treatment is received by people of different ethnic groups from the British National Health Service. Using data from the General Household Surveys of 1984-91 it examines the use of general practitioner, outpatient services using three different methods to adjust for need and for other possible confounding variables. The results do not suggest there is any gross pattern of inequity between ethnic groups, except perhaps with respect to the Chinese population which displays consistently low levels of utilisation. However, while use of GP services by minority ethnic groups is in general as high or higher than the white population, use of outpatient service is low. Some of the results also suggest that there may be important ethnic differences underlying the broader finding of equity. For example, females of Pakistani origin report low levels of GP use. More generally, excess use of GP services among several minority ethnic groups appears to be associated with need, while people from most minority ethnic groups who do not report illness display especially low use of outpatient services relative to the corresponding group in the white population. The paper examines the implications of these findings.

Subjective unmet need and utilization of health care services in Canada: what are the equity implications?

This study aimed to evaluate whether subjective assessments of unmet need may complement conventional methods of measuring socioeconomic inequity in health care utilization. This study draws on the 2003 Canadian Community Health Survey to develop a conceptual framework for understanding how unmet need arises, to empirically assess the association between utilization and the different types of unmet need (due to waiting times, barriers and personal reasons), and to investigate the effect of adjusting for unmet need on estimates of income-related inequity. The studys findings suggest that a disaggregated approach to analyzing unmet need is required, since the three different subgroups of unmet need that we identify in Canada have different associations with utilization, along with different equity implications. People who report unmet need due to waiting times use more health services than would be expected based on their observable characteristics. However, there is no consistent pattern of utilization among people who report unmet need due to access barriers, or for reasons related to personal choice. Estimates of inequity remain unchanged when we incorporate information on unmet need in the analysis. Subjective assessments of unmet need, namely those that relate to barriers to access, provide additional policy-relevant information that can be used to complement conventional methods of measuring inequity, to better understand inequity, and to guide policy action.