Robin G. Milne

Financial incentives, competition and a two tier service: lessons from the UK National Health Service internal market

The experience of General medical practitioner (GP) fundholding is analysed for evidence of the response by family doctors to financial incentives. An analysis of consultant outreach, the local provision of out-patient services, in Scotland finds little evidence of a response, based on comparing the experience of fundholders with non-fundholders. At least in the case of hospital based services, financial incentives seem to be of secondary importance. Financial incentives for such services depend on consultant compliance which, arguably, was missing when it came to creating a two-tier service which deliberately favoured patients from fundholding practices.

Public Capital Project Appraisal: A Real Cause for Concern and for Whom?

This study finds further evidence of discrepancies between theory and practice in the evaluation of capital schemes in the public sector. This is a common pheno menon in the private sector too, despite its apparently greater incentive to use the formal approach recommended by the Treasury. Proposals by the Controller and Auditor General - that the public sector should alter its practice to conform to the Treasurys guidelines - may be less appropriate than fresh thinking about what these guidelines should be, especially the uses of discounting (DCF) to represent the opportunity cost of capital, and of sensitivity analysis and probability theory to cope with risk and uncertainty. In other respects there is evidence of much more conformity of practice with theory than a study by the Controller and Auditor General would suggest.

The Decline of Fertility in Malta: The Role of Family Planning

This paper examines the role that family planning played in the decline of fertility in Malta. In 1993 the authors carried out a survey of family planning, similar to one carried out by one the authors in 1971. The analysis of these two surveys suggests that the practice of family planning has not increased significantly in this period. However, there has been a sharp change in the type of method used. More specifically, there has been a shift away from traditional methods (such as coitus interruptus) to more efficient methods (such as the contraceptive pill). There are now a range of affordable methods of contraception available in Malta. Regression techniques are used to model the choice of contraceptive method. The main aim of the empirical analysis is to establish what characteristics are associated with the use of efficient methods of contraception.

Using economic analysis to increase civic engagement

Two well-established insights of economic analysis are applied to four case studies on civic disengagement: the use of incentives implicit in supply-and-demand analysis and marginal analysis. The case studies comprise social security, housing benefit, hospital consultant outpatients and free school meals (FSMs). The case studies support the propositions that incentives can work or are thought to do so, and that the higher the take-up, the larger the benefit. But other factors can override, and significant proportions do not respond in the predicted way. In the case of the spare room subsidy, the policy-makers’ goals were arguably unrealistic. In the case of Working Tax Credit and Pension Credit, the reasons are far from clear. Marginal analysis is used to quantify how much it could cost to increase take-up, when the take-up of a means-tested benefit is already nearly universal, as it had been for FSMs among primary school pupils. The chosen method, universal free provision for P1–P3 children, would seem disproportionate, unless the main reason for this policy has been to impact all children, and not just those who had been means tested. This case study shows the importance of marginal analysis when designing policies to increase civic engagement.

Using administrative innovation to address missed consultant outpatient appointments

An administrative innovation for booking outpatient appointments has been introduced in Wales, Scotland and Northern Ireland, variously known as ‘patient-focussed booking’ (PFB) and ‘partial booking’. It has three distinct features: patients must confirm their wish to have an appointment; patients are given a choice of date, time and place for the appointment; and the appointment is booked only a short time in advance of the due date. Previous studies have shown a reduction in missed booked appointments, either because the patient could not attend (CNA) or did not attend (DNA). Our results, covering a more recent period, confirm these findings, and show they can be sustained for longer periods. The requirement that patients must confirm their wish to have an appointment can lead to some referrals not ending up as booked appointments. Some may choose to withdraw; others simply did not reply, ‘non-responders’. Either way, those that do not are referred back to their GP. This study finds non-response was much less common that previous studies. However, it was common enough to offset the effect of PFB on missed booked appointments due to CNA and DNA. To that extent, the innovation did not make much change to civic disengagement, except for providers who are now better able to plan clinics.

Unemployment in Malta, 1956–71

A statistical analysis of unemployment between 1956 and 1971 shows that the factors influencing it in Malta are similar to those for more developed countries: unemployment varied with demand deficiency and the opportunity cost of working. The absence of a secular change in unemployment for both sexes combined masked the secular increase for men and decrease for women; and other evidence supports the conclusion that women were being substituted for men in the labour force. Finally, the analysis of emigrants most likely to be in the labour force in Malta showed that the rate of emigration is also responsive to local labour market conditions, although not to the provision of social security for those of working age.

Recent trends in civic disengagement

This study takes as its point of departure Putman’s classic study, Bowling Alone, on disengagement among voluntary organisations in America. This study views disengagement in terms of absence from pre-arranged situations, such as booked appointments, and the non-takeup of statutory means-tested benefits. Whereas Putman finds disengagement in America became more common from the 1960s, we find the opposite in the United Kingdom over the last 10 to 20 years. Central governments in the United Kingdom have been active in addressing absence and non-takeup in the areas studied. Absence may be a problem for schools, hospitals and the workplace, but for some pupils and employees they may be a symptom of poor relations within the organisation, and for some patients the outcome of the hospital’s administrative failure. A common stated feature in the non-takeup of means-tested benefits is the stigma associated with it. By way of contrast, the takeup of Child Benefit had been virtually complete. The question – whether the high takeup was because of the administrative simplicity of Child Benefit and its significant cash benefits over the long term, or because it was not means tested – might be resolved post-January 2013, when its eligibility and the size of benefit became income based.

Competitive provision of public services: cost savings over successive rounds of tendering

ABSTRACT We study the evolution of the cost of public service provision when subjected to a competitive tendering process. We add to the existing literature by analysing cost savings over successive rounds of tendering. Previous results in the literature show that initial cost savings tend to disappear over time with the age of the contract. Our findings suggest that each additional round of tendering will be followed by a renewal of cost savings. Thus, keeping competitive pressure via periodic tendering appears to address the problem.