Les Mayhew

Equity, Efficiency, and Accessibility in Urban and Regional Health-Care Systems

This paper explores four different criteria of health-care resource allocation at the urban and regional level. The criteria are linked by a common spatial-interaction model. This model is based on the hypothesis that the number of hospital patients generated in a residential zone i is proportional to the relative morbidity of i, and to the availability of resources in treatment zone j, but is in inverse proportion to the accessibility costs of getting from i to j. The resource-allocation criteria are based on objectives on which there is broad agreement among planners and other actors in a health-care system. These objectives are concerned with allocations that conform to notions of equity, efficiency, and two definitions of accessibility. The allocation criteria give mainly aggregate-level information, and are designed with the long-term regional planning of health-care services in mind. The paper starts by defining the criteria, and describes how they are intended to be employed in a planning context. The allocation rules are then formally derived and linked together mathematically. They are then applied to a region, London, England, which is known to have very complex health-care planning problems. As a result of this application, two of the criteria—equity and efficiency—are selected for further analysis. A new model is built and applied that specifically enables the user to trade off one of these criteria against the other.

On The Sustainability of the UK State Pension System in the Light of Population Ageing and Declining Fertility

As a result of population ageing and declining fertility, the UK state pension system is unlikely to continue to be able to deliver the current level of pensions without some combination of a higher state pension age and a steady inflow of young immigrant workers from abroad. However, with prudent economic management and continuing economic growth, the need for additional immigrants can be contained and modest real increases in pensions are also a possibility. Higher economic activity rates among older people, including deferred retirement, will to some extent compensate but not eliminate these pressures. If fertility picks up over the next few years, this will also help, but not until after 2030.

Optimizing the benefits of urban road user charging

Traffic congestion is a feature of most modern cities but attempts to control it or limit its effects have met with only modest success. There is significant and continuing interest in the concept of charging city vehicle users, although apart from the use of parking charges actual operational schemes are few and far between. In this paper, we compare three alternative charging policies using a simplified model of travel demand and supply, which we combine with cost benefit techniques. The charging policies are area-based charging in which users pay to locate in or enter an area, terminal-charging based on supplementary parking fees in residential and non-residential locations and distance-based charging which is a charge related to how far users travel. The model allows for behavioural effects resulting from trip diversion and demand suppression, as well as capacity restraint (speed-flow feedback effects based on limited route capacity). In the case study, we parameterize the model using data and geographical dimensions based on London. We show that area based charging delivers the least benefits whilst a hybrid policy based on terminal and distance-based charges delivers the most. Because it is of topical interest, we compare our results and predictions with the Mayors strategy for London, which is an area-based scheme. We conclude that the revenue generated using a hybrid policy would be as great as for an area based scheme whilst at the same time delivering substantially greater benefits to road users in terms of travel time and other savings.

Waist-to-height ratio is more predictive of years of life lost than body mass index.

Objective Our aim was to compare the effect of central obesity (measured by waist-to-height ratio, WHtR) and total obesity (measured by body mass index, BMI) on life expectancy expressed as years of life lost (YLL), using data on British adults. Methods A Cox proportional hazards model was applied to data from the prospective Health and Lifestyle Survey (HALS) and the cross sectional Health Survey for England (HSE). The number of years of life lost (YLL) at three ages (30, 50, 70 years) was found by comparing the life expectancies of obese lives with those of lives at optimum levels of BMI and WHtR. Results Mortality risk associated with BMI in the British HALS survey was similar to that found in US studies. However, WHtR was a better predictor of mortality risk. For the first time, YLL have been quantified for different values of WHtR. This has been done for both sexes separately and for three representative ages. Conclusion This study supports the simple message “Keep your waist circumference to less than half your height”. The use of WHtR in public health screening, with appropriate action, could help add years to life.

The Role of Private Finance in Paying for Long Term Care

An ageing population and increased longevity means that long term care will become progressively more expensive. In 2009 the Government published a Green Paper on future funding options and a White Paper in 2010. This article considers the role of private finance products under the ‘Partnership’ option. It finds that few households are able to pay for LTC based on income and savings but the number increases if housing assets are included. We show that products can be devised for a range of circumstances, although state support would need to continue. We propose a simplified means testing system based on a combination of income and assets.

Predicting Patient Flows and Hospital Case-Mix

In recent years, there has been an increasing interest in the spatial modelling of health care services: to locate services in a more equitable and efficient manner; to cope with the consequences of structural change in demography and accessibility to services; to examine the interactions between different services over space and time. In this paper, one particular spatial model used for analysing impact on patient flows, catchment populations, and other key variables resulting from changes in supply, demand, or accessibility is examined in depth. Used in several countries for planning purposes, the model was originally developed in 1979 by the Operational Research Service of the Department of Health and Social Security in the United Kingdom, for the London Health Planning Consortium. It was later refined at the International Institute for Applied Systems Analysis in Laxenburg, Austria. In the present study the robustness of prediction is tested on four versions of the basic model developed at the University of Newcastle, Australia, in 1984 and applied to data from the Sydney Metropolitan Region. Key outputs from the model are examined and the extent to which it correctly predicts changes in service levels over a three-year period in the case of five different acute clinical specialties is shown. To conclude the paper, the technical details of case-mix model are presented, which combines different acute service categories with the spatial dimension to provide a more comprehensive framework for predicting and analysing the behaviour of, and interactions between, supply and demand.

Interactions between the supply of and demand for hospital services in London

This paper describes some of the work done by the Operational Research Service of the Department of Health and Social Security concerned with health care planning for London and the surrounding counties. The emphasis of the paper is on the development of a model of the interaction between the spatial distribution of in-patient facilities and levels of admission to hospital for residents of different localities. The background to the work is first explained and the need for such a model examined. The structure of the model is briefly outlined and the ways in which it can be used by health care planners are explored. The model provides a powerful tool for use in assessing the impact on local populations of various geographical resource configurations. At present this model is calibrated specifically for the South East of England; however, the approach could usefully be applied in many other areas of the country and elsewhere in the world.

Human Survival at Older Ages and the Implications for Longevity Bond Pricing

Abstract Governments are concerned about the future of pension plans, for which increasing longevity is judged to be an important risk to their future viability. We focus on human survival at age 65, the starting age point for many pension products. Using a simple model, we link basic measures of life expectancy to the shape of the human survival function and consider its various forms. The model is then used as the basis for investigating actual survival in England and Wales. We find that life expectancy is increasing at a faster rate than at any time in history, with no evidence of this trend slowing or any upper age limit. With interest growing in the use of longevity bonds as a way to transfer longevity risks from pension providers to the capital markets, we seek to understand how longevity drift affects pension liabilities based on mortality rates at the point of annuitization, versus what actually happens as a cohort ages. The main findings are that longevity bonds are an effective hedge against longevity risk; however, it is not only the oldest old that are driving risk, but also more 65-year-olds reaching less extreme ages such as 80. In addition, we find that the possibility of future inflation and interest rates could be as an important a risk to annuities as longevity itself.

Disability--Global Trends and International Perspectives

Disability among populations is widespread and although many studies on disability exist worldwide there is a lack of comparability between countries and also between studies in the same country. Yet despite a lack of clarity, disability is an increasingly major issue in public policy terms from the standpoints of equal opportunities, the increasing burden of age-related disability, work participation, social security benefits and so forth. One of the main problems is that disability is defined differently for different purposes so that there is no consistent overview of disability among populations, or the implications for disability policies. The first part of this paper addresses these deficiencies by reviewing and analysing global data on disability and relating it to ageing, health status, and functional measures of disability. It finds that a major cause of disability in future years will be ageing but that the prevalence of disability will depend on socio-economic factors and trends in healthy life expectancy. The second part of the paper considers policies for tackling disability, particularly the financial aspects and the role of the public and private sectors, and finds a multiplicity of institutional arrangements in place. The paper concludes by identifying five major issues for public policy--economic development, ageing and long-term care, the importance of developing work potential, and the need for international standards in the area of disability data.

ACTIVE AGEING IN THE UK-ISSUES, BARRIERS, POLICY DIRECTIONS

Active ageing is defined as allowing people to remain independent and achieve their potential regardless of age. However, age is also a device used widely in society for assigning or taking away responsibilities, allocating resources or determining access to services on age grounds, or as a proxy for mental and physical well being. This paper is one of several prepared by the Active Age consortium funded by the European Union to undertake a review of the institutional framework in each participant country and how this shapes policies towards older people, including the barriers and opportunities affecting active ageing1. The expected outcome of this phase of research is a comprehensive overview of active ageing strategies in Europe, including barriers to active ageing, as well as a map of the socio-institutional and political landscape in which active ageing policies operate. This paper argues that the UK is quite well advanced in preparing and defining policies, but that some of the high public profile is as a result not of ageing as such, but issues arising in specific areas such as employment, education, pensions, health and health care.