Variations and value improvement in back pain care in one area of England.

The pursuit of value and equity have been put on a legal footing in the NHS with the arrival of the legal duty for all in the NHS to improve health and well-being of the population served, to provide fair access to high quality healthcare, and to use resources sustainably and efficiently. Recognising this we used analysis of variation to help us understand the degree to which we were fulfilling our new duty for people with back pain in Mid-Nottinghamshire and where there might be opportunities for value improvement.MSK Together is a group of clinical and managerial representatives from providers, purchasers, local government, and patients who work collectively to optimise the use of resources for people with MSK conditions in Mid-Nottinghamshire.

Institutional boundaries and the challenges of aligning science advice and policy dynamics: the UK and Canada in the time of COVID-19.

This comparison of institutions of science advice during COVID-19 between the Westminster systems of England/UK and Ontario/Canada focuses on the role of science in informing public policy in two central components of the response to the pandemic: the adoption of non-pharmaceutical interventions (NPIs) and the procuring of vaccines. It compares and contrasts established and purpose-built bodies with varying degrees of independence from the political executive, and shows how each attempted to manage the tensions between scientific and governmental logics of accountability as they negotiated the boundary between science and policy. It uses the comparison to suggest potential lessons about the relative merits and drawbacks of different institutional arrangements for science advice to governments in an emergency.

How valid are projections of the future prevalence of diabetes? Rapid reviews of prevalence-based and Markov chain models and comparisons of different models' projections for England.

Objectives: To examine validity of prevalence-based models giving projections of prevalence of diabetes in adults, in England and the UK, and of Markov chain models giving estimates of economic impacts of interventions to prevent type 2 diabetes (T2D).

Methods: Rapid reviews of both types of models. Estimation of the future prevalence of T2D in England by Markov chain models; and from the trend in the prevalence of diabetes, as reported in the Quality and Outcomes Framework (QOF), estimated by ordinary least squares regression analysis.

Reputations count: why benchmarking performance is improving health care across the world.

This paper explores what motivates improved health care performance. Previously, many have thought that performance would either improve via choice and competition or by relying on trust and altruism. But neither assumption is supported by available evidence.

A scoping review protocol to map the evidence on interventions to prevent overweight and obesity in children.

Introduction: Obesity has become one of the biggest public health problems of the 21st century. Prevalence of obesity in children and adolescents has increased dramatically worldwide over the last 20 years, and this trend is expected to continue. Obesity in childhood is concerning as it predicts obesity in adulthood, a common risk factor for a wide array of chronic diseases and poor health outcomes.

Visualizing value for money in public health interventions.

Background: The Socio-Technical Allocation of Resources (STAR) has been developed for value for money analysis of health services through stakeholder workshops. This article reports on its application for prioritization of interventions within public health programmes.

Methods: The STAR tool was used by identifying costs and service activity for interventions within commissioned public health programmes, with benefits estimated from the literature on economic evaluations in terms of costs per Quality-Adjusted Life Years (QALYs); consensus on how these QALY values applied to local services was obtained with local commissioners.

Preventing type 2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programmes and metformin, with and without screening, for pre-diabetes.

Objective: Explore the cost-effectiveness of lifestyle interventions and metformin in reducing subsequent incidence of type 2 diabetes, both alone and in combination with a screening programme to identify high-risk individuals.

Design: Systematic review of economic evaluations.

Data Sources And Eligibility Criteria: Database searches (Embase, Medline, PreMedline, NHS EED) and citation tracking identified economic evaluations of lifestyle interventions or metformin alone or in combination with screening programmes in people at high risk of developing diabetes.

What Can We Learn from the UK's "Natural Experiments" of the Benefits of Regions?

Marchildon highlights the lack of evidence on policies of regionalization in Canada: with regionalization being in favour in the 2000s followed by disillusion and the abolition of regions by some provincial governments. This paper looks at evidence from the UK's single-payer system of the impacts of regions on the performance of the delivery of healthcare. In England, regions were an important part of the hierarchical structure of the National Health Service (NHS) from its beginning, in 1948, to the introduction of provider competition, in the 1990s.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England.

Objectives: To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.

Study Design: This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.

Incentives and models of governance.

This short commentary on Oliver's review of incentives relates that review to four models of governance: Trust and Altruism (T&A), Choice and Competition (C&C), Naming and Shaming (N&S) and Targets and Terror (T&T).

STAR--people-powered prioritization: a 21st-century solution to allocation headaches.

The aim of cost effectiveness analysis (CEA) is to inform the allocation of scarce resources. CEA is routinely used in assessing the cost-effectiveness of specific health technologies by agencies such as the National Institute for Health and Clinical Excellence (NICE) in England and Wales. But there is extensive evidence that because of barriers of accessibility and acceptability, CEA has not been used by local health planners in their annual task of allocating fixed budgets to a wide range of types of health care.

Using an epidemiological model to investigate unwarranted variation: the case of ventilation tubes for otitis media with effusion in England.

Objectives: To investigate unwarranted variation in ventilation tube insertions for otitis media with effusion in children in England. This procedure is known to be 'overused' from clinical audits, as only one in three ventilation tube insertions conforms to the appropriateness criteria of the National Institute for Health and Care Excellence (NICE); but audits cannot identify the scale of 'underuse' - i.e.

The political economy of rationing health care in England and the US: the 'accidental logics' of political settlements.

This article considers how the 'accidental logics' of political settlements for the English National Health Service (NHS) and the Medicare and Medicaid programmes in the United States have resulted in different institutional arrangements and different implicit social contracts for rationing, which we define to be the denial of health care that is beneficial but is deemed to be too costly. This article argues that rationing is designed into the English NHS and designed out of US Medicare; and compares rationing for the elderly in the United States and in England for acute care, care at the end of life, and chronic care.

A population health approach to reducing observational intensity bias in health risk adjustment: cross sectional analysis of insurance claims.

Objective: To compare the performance of two new approaches to risk adjustment that are free of the influence of observational intensity with methods that depend on diagnoses listed in administrative databases.

Setting: Administrative data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions.

Design: Cross sectional analysis.

From data to decisions? Exploring how healthcare payers respond to the NHS Atlas of Variation in Healthcare in England.

Purpose: Although information on variations in health service performance is now more widely available, relatively little is known about how healthcare payers use this information to improve resource allocation. We explore to what extent and how Primary Care Trusts (PCTs) in England have used the NHS Atlas of Variation in Healthcare, which has highlighted small area variation in rates of expenditure, activity and outcome.

Methods: Data collection involved an email survey among PCT Chief Executives and a telephone follow-up to reach non-respondents (total response: 53 of 151 of PCTs, 35%).

Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims.

Objective: To determine the bias associated with frequency of visits by physicians in adjusting for illness, using diagnoses recorded in administrative databases.

Setting: Claims data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions.

Design: Cross sectional analysis.

The rise of the regulatory state in health care: a comparative analysis of The Netherlands, England and Italy.

In a relatively short time, regulation has become a significant and distinct feature of how modern states wish to govern and steer their economy and society. Whereas the former 'dirigiste' state used to be closely related to public ownership (e.g.

Modelling the impact on avoidable cardiovascular disease burden and costs of interventions to lower SBP in the England population.

Background: The burden of disease from cardiovascular disease (CVD) remains significant in England. Blood pressure remains an important risk factor. Health gain through public health measures and improving treatment compliance are potentially likely to be high.

Why hasn't integrated health care developed widely in the United States and not at all in England?

There have been influential advocates for financing and organizing health care in the United States and England based on the model of integrated health care delivery systems (IHCDSs). Despite good evidence that a few IHCDSs provide high-quality health care economically, such organizations are rare and localized in a few market areas in the United States and are absent in the English National Health Service (NHS). The explanation of why this is so includes various contributory factors: the way the development of the medical profession in each country pursued specialization; the division in British medicine between general practitioners and specialists; and the characteristics that we identify of established successful IHCDSs, which created formidable barriers to entry for a new IHCDS.

Choice of providers and mutual healthcare purchasers: can the English National Health Service learn from the Dutch reforms?

In the 1990s, countries experimented with two models of health care reforms based on choice of provider and insurer. The governments of the UK, Italy, Sweden and New Zealand introduced relatively quickly 'internal market' models into their single-payer systems, to transform hierarchies into markets by separating 'purchasers' from 'providers', and enabling 'purchasers' to contract selectively with competing public and private providers so that 'money followed the patient'. This model has largely been abandoned where it has been tried.

Changing choices in health care: implications for equity, efficiency and cost.

Although choice may be seen as an end in itself, the papers included in this special issue of Health Economics, Policy and Law, examine choice policies in European systems of health care, which aim to be effective instruments for ameliorating the systemic pressures from the iron triangle of equity, efficiency, and cost. Three papers consider the nature of differences between and within countries following the Beveridge and Bismarck models of financing and organising the delivery of care, and how choices are changing within different systems. Within countries following the Beveridge model, current policies in England, Denmark and Sweden emphasise increasing patient choice of provider.