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Research project
Understanding competition and choice in the NHS
Funded by: Nuffield Trust
Date started: 01 September 2012

The Government's reforms pave the way for more competition for the provision of health services. This project, conducted in partnership with the Nuffield Trust, will establish a long-term expertise in the use of competition and market mechanisms in health care in England and internationally.

Project 1: Where are patients treated?

Since 2006, NHS policy has stated that patients referred for specialist treatment should be offered a choice as to where they attend their first outpatient appointment.

This replaced a regime of undisclosed or implicit choice, where patients could state a preference but that option was not made explicit. A large majority of patients attended their nearest NHS Trust or default hospital.

There is now a body of evidence that the extension of patient choice, under fixed prices, has been associated with improvements in hospital quality - see Cooper et al, 2011 and Gaynor et al, 2010.

However, there is very little information on the mechanisms driving these results. In particular, there is a lack of evidence on how patients responded to increases in choice, and the extent to which any changes are consistent with the level of observed quality improvements.

This project will consider how patterns of outpatient attendances and inpatient admissions have changed since 2005/6. The results will be important for understanding the effectiveness of expanding patient choice as a way of improving quality and efficiency.

We will publish this report in late 2012.

Project 2: Variations in responses to increased patient choice

The second project aims to understand whether increased choice has had a greater impact on patterns of referral for certain types of patients or in certain types of GP practice, and the consequent implications for the equity of NHS health care provision.

More specifically, it will:

  • Describe how changes in distribution of patients across hospitals vary between areas, across patient characteristics, and by GP;
  • Test for differences in referral patterns across primary care trusts (PCTs) or GP practices with very similar characteristics;
  • Seek to understand what types of patients have responded more to increased choice, and why.

We expect to publish this report in 2013.

Project 3: Treatment Pathways

The first two projects consider outpatient and inpatient records in isolation. However, these records represent two points on much longer and more complex treatment pathways.

Equally, existing published work has tended to focus on the end of a treatment pathway, either in terms of hospital admission or patient outcomes. There is much less evidence on the experiences of patients and the decisions of health care workers along the way.

By understanding how competition affects patient care at different points in the treatment pathway, we aim to gain an insight into the mechanisms behind existing published results; and isolate levers that might prove effective in improving the future quality of care.

Given the overall complexity of treatment pathways, we are focusing on four steps in the referral chain where the potential impacts of competition could be particularly important:

  • The GP’s decision to refer as observed through the presence of outpatient appointments;
  • The volume of intra-trust activity, particularly in areas where trusts are paid per outpatient activity;
  • Consultant to external consultant referrals;
  • The outpatient consultant’s decision to admit for inpatient treatment.

We expect to publish this report in 2013.

Related publications
Publications by type

18 December 2013
External publications
This report is published by the Nuffield Trust as part of the joint IFS and Nuffield Trust project, 'Understanding competition and choice in the NHS'.
08 July 2013
This paper was given at an event organised by Conservative Health on 8 July 2013 at Portcullis House.
22 May 2013
External publications
The changing landscape of health care in the 2000s
19 November 2012
External publications
This report forms part of research to establish a long-term expertise in the use of competition and market mechanisms in health care – both in the NHS in England and internationally.


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