1. Effects of choice and market reform on inequalities of access to health care Dr Richard Cookson Senior Lecturer and MRC Fellow University of York

2. Funding body: NHS R&D Service, Delivery and Organisation Programme Project duration: 1 April 2007 - 31 March 2010 Host institution:University of York Lead investigator: Richard Cookson Co-applicants:Mark Dusheiko, Diane Dawson, Russell Mannion Consultants:Roy Carr-Hill, Hugh Gravelle, Andrew Street, Geoffrey Hardman, Steven Martin, Jake Abbas (YHPHO) Yorkshire & Humber Public Health Observatory Department of Social Policy and Social Work The York Management School Department of Economics and Related Studies Effects of choice and market reform on inequalities of access to health care

3. The changing social gradient in elective hip replacement in the English NHS, 1991 vs. 2001 (Age-sex standardised utilisation ratios by 50 Townsend deprivation quantiles of wards - smoothed data) Background – An Illustrative Example of Pre-Existing NHS Inequality

4. Research aims 1.To quantify inequality trends in English NHS 2001/2 to 2008/9, for: a)All general categories of hospital activity b)A representative selection of diagnostic & therapeutic procedures 2.To test hypotheses about inequality effects of geographically varying aspects of choice and market reform, such as: a)The local degree of choice / competition b)The local share of independent sector provision c)The local degree of financial pressure to close unprofitable services 3.To test hypotheses about other factors driving inequality trends, such as: a)Hospital supply factors (e.g. unit cost, length of stay) b)GP supply factors (e.g. GPs per head)

5. Research limitations 1.Focus on inequality between small areas –Suitable national patient level data not available 2.Focus on socio-economic inequality –Will also examine age and ethnicity –Hampered by changing relative needs (age) and poor data recording (ethnicity) 3.Focus on inequality in use of care (activity) –Not inequality in use of choice –Will also examine inequality in waiting times and inequality in local supply of GPs/specialists/beds

6. Hypotheses about links between health reform and inequality 1.Local service closures –Disadvantaged patients may be less able to travel 2.Perverse incentives in competitive areas –“creaming”, “skimping”, and “dumping“ 3.Patient demand may outstrip need in affluent areas 4.Activity skew towards profitable “cure” activity –Away from complex, labour-intensive “care” activity (Tudor-Hart, J (2006) Political economy of health care p.18-19)