Context and problem statement

Work in ESHCRU to date has examined market dynamics of care homes markets nationally, looking at the effects of competition on prices and quality and competition on market exit rates. We have also examined substitution effects between care homes markets and domiciliary care providers. Nonetheless, there is significant scope to improve the understandings of social care markets in England, particularly at a more local level.

Reductions in social care expenditure by local authorities have impacted the care homes market through reduced prices for publicly-supported residents (or non-inflationary increases). This has put providers under increasing pressure and our previous work (Forder and Allan, 2014) showed that the power of local authority commissioners in the market to reduce prices causes quality to decrease through competition.

Social care expenditure reductions are likely to differ in how they affect local social care markets. Even local markets that appear strong may be seeing an increased polarisation in services between basic and high quality providers.

Project aims

The overall aim of this project is to improve our understanding of factors that affect changes in the supply in local social care markets.

1. Building on the assessment of the national care homes market, we will descriptively analyse differences in local authority care home markets (levels of competition, quality, entry and exit).
2. We will analyse local social care markets in general, particularly concentrating on describing the different forms of social care available in two LA markets, examining the economic factors that act as enablers or barriers to different forms of social care provision.

To quantitatively assess whether differences in local authority expenditure cause provider entry and exit in local care homes markets, and to what extent.

Context and problem statement

In general, high vacancy and turnover rates are heavily influenced by low pay, low job satisfaction and lack of opportunities for career advancement. Yet little is known about the determinants of the current substantial turnover and vacancy rates in the social care sector. Factors that can help explain and inform the development of solutions to workforce stability issues in social care are of great interest, given the current shortage of social care workers in England. Reduced turnover and vacancy rates would promote care home and home care quality and create efficiencies in the costs of staffing.

Social care is a low-pay sector, with wages of care staff at or just above minimum wage rates. Earlier work in ESHCRU showed that the introduction of the National Living Wage in April 2016 created an increased compression of wages around the minimum. However, a significant minority of workers were paid above the minimum wage. Non-pay factors might explain the quite important wage dispersion between social care establishments. Understanding the impact of higher wages and better conditions of employment can promote social care as a vibrant and rewarding sector.

Project aims

The main research aims are:

1. To assess the main factors affecting staff turnover and vacancy rates in the social care sector, in particular those that can be addressed by social care providers and policies.
2. To examine the relationship between pay and conditions of home care staff and the quality of care provided by their employing home care agencies as rated by the Care Quality Commission (CQC).
3. To give an overview of the social care labour market, including the distribution of wages and non-pay compensation by geography and service type, and provide comparisons with other sectors (e.g. retail trade and hospitality) competing in local labour markets.

Context and problem statement

NHS England has announced that practices are to be encouraged to work together in hubs or networks or Federations with a combined list size of 30 to 40,000 patients (Five Year Forward View – Next Steps). The rationale is that this scale will allow practices to share facilities and resources and hence improve outcomes. But there is little robust evidence. The limited quantitative evidence reports mixed findings and used cross section comparisons.

Project aims

1. What are the effects of larger general practices on clinical quality and patient reported outcomes such as satisfaction.
2. What are the effects of Federations and similar organisations of practices on clinical quality and patient reported outcomes.

Context and problem statement

Hospital service configuration (location, specialisation, and size of hospitals) may have a considerable impact on providers’ efficiency and quality and on accessibility for patients.  The analysis will provide evidence of the wider implications of hospital service configuration, with special focus on small providers, and their potential closure or merger. It will inform policy on whether small hospitals as a whole provide lower quality. If so, there may be a case to close them or merge them, and relocate patients to more distant providers.

Project aims

The project is designed to:

i) assess whether small NHS Trusts have lower quality compared to larger Trusts, where quality will be measured by hospital-level markers such as CQC rating, hospital-acquired infections, patient satisfaction,  overall mortality and by mortality rates for selected conditions (such as acute myocardial infarction (AMI), hip fracture and stroke).

ii) assess implications of reconfigurations, such as closure or a merger, for elective patients in terms of distance and quality.

Context and problem statement

Little is known about whether and how market structure and patient choice also affect the efficiency and productivity of hospitals and patient waiting times, a key measure of accessibility and responsiveness.  This analysis determine whether hospitals with different market structure and configuration vary in quality, efficiency, productivity and the way they make access more easily available to patients. It will also highlight whether hospitals with higher quality may experience longer wait as a result of greater choice and relocation of patients from high- to low-quality hospitals.

Project aims

The project research questions are (i) does market structure affect hospital efficiency, productivity, and waiting times and its distribution across hospitals and (ii) do these effects depend on the extent to which patients can exercise choice (with potentially high-quality hospitals offering longer waits and low-quality hospitals shorter ones)?

Context and problem statement

Increasingly, the Independent (private) Sector and dedicated Treatment Centres are providing common elective procedures such as hip replacement and cataract surgery to NHS patients. This project will inform whether the NHS should change hospital configuration by further expanding contracting to either the private sector (ie the Independent Sector), and/or dedicated facilities that focus on high-volume elective care.

Project aims

The project will test for differences in hospital emergency readmissions between Acute Trusts, Independent Sector and Treatment Centres. The analysis will therefore focus on a measure of clinical quality which can be applied to all elective procedures provided by the Independent Sector and by Treatment Centres.

Context and problem statement

Relatively little is known about the operation of the care homes market in England. A particular issue is the sustainability of large providers in the care home sector. Understanding the financial health of providers and predicting whether there is a significant risk of bankruptcy is key to avoiding the disruption to care associated with changes in ownership and management, and possibly with the closure of a care establishment.

Project aims

The overall aim of this project is to gain a better understanding of the factors that affect (potential) changes in supply in the care homes market. In particular, we are interested in identifying and quantifying the impact of factors that might be affected by policy including competition, financial health and external factors such as local market characteristics.

This project has two main objectives:

• We will explore the characteristics (e.g. quality, price and type/ownership) of new providers that enter the market and investigate the degree to which supply-side change (entry and exit) in care home markets is dependent on those and other characteristics of the local market (including levels of competition, locational characteristics, average care home prices and average house prices).
• We will examine which provider and local area characteristics are correlated with financial risk of residential care providers in England, in order to develop an index of “financial frailty” in the care sector. These findings should help identify providers at risk and therefore support effective early intervention and the implementation of turnaround strategies.

Context and problem statement

Little is known about the impact that increased provision of domiciliary care might have on the care homes market. This work will help policy makers understand the consequences of policies to promote the increase of home-based care options. In the context of tightening budgets and increased eligibility thresholds which mostly affect access to home care, this research will help us to assess the consequences for the demand for care home services.

Project aims

The main aim is to analyse the impact that the increase in home care provision may have had on supply (including entry and exit) in the care homes market.

Context and problem statement

The project will provide policy makers with new information about the relationship between general practice expenditure, skill mix and patient outcomes. It will identify variation in expenditure per patient both with and without controlling for patient characteristics and outcomes.

Project aims

The project aims are (i) to explore and summarise the cross section relationships between expenditure, skill mix, quality and outcomes and (ii) when subsequent years of data become available to investigate if the cross-section relationships are robust and if they provide evidence for causal effects.

Context and problem statement

Patient choice of general practice is influenced by general practice quality. This project builds on earlier work to inform policy makers concerned about policies to encourage entry of new practices and new types of provider about the potential effects of market structure on quality.

Project aims

The project research question is whether practices exposed to more competition have higher quality.

Context and problem statement

Relatively little is known about the factors that facilitate or constrain the development of extra care housing provision, especially given the ‘mixed economy’ structure of the care sector. The research will help to identify barriers and enablers for extra care housing, including private, for-profit, provision.

Project aims

The project has four linked aims:
(a) To explore the availability and potential of models of care with accommodation
(b) To explore the potential for substitution with care home services
(c) To explore the role of housing with care in supporting health and providing a stable location for healthcare delivery
(d) To consider issues of funding and supply

Context

Government policy proposals have strongly signalled an intention to increase the competitiveness of health markets by reducing regulation and improving information resources to reduce problems of information asymmetry. The potential issue of collusive and anti-competitive behaviour of healthcare providers (GP practices, hospitals) on the provision of quality is also on the policy agenda. This was reflected in the creation of Competition and Co-operation Panel.

NHS markets are characterised by centrally determined prices and a mixture of incentives and regulation aimed at ensuring quality. Social care markets are highly competitive and feature price and quality competition (with regulation of minimum quality standards and licensing).

Personalisation and Choice reforms have pushed demand-side choice to patients and service users, potentially improving the competitiveness of markets. With the establishment of GP consortia and the opportunity for people to choose with which GP to register, a framework is in place for people to be effectively choosing their health care commissioner.

The overall aim of this project is to establish whether increases in competition in hospital, primary care, and social care markets leads to improvements in the outcomes of people using services. The following projects develop this area of work:

Q1 Effects of market structure and ownership on social care quality and outcomes

Aims

The vast majority of social care services are procured in markets from independent (private and voluntary sector) providers. A more thorough understanding of how markets operate and their implications is a high priority for research. We to establish whether increases in competition lead to improvements in the outcomes of people using care home services. We will use information on the organisational form and ownership of care homes to better delineate the impact of competition. We will compile data from different years to form a panel that allows assessment of competition effects both geographically and through time.

Q2 Hospital quality competition under fixed prices

Context

The relationship between the quality of health care and the extent of competition amongst providers has been the subject of intense policy interest and debate. As part of the ESCHRU programme we are undertaking a set of related investigations into this relationship in the hospital sector, in primary care (general practices) and in social care. We will test whether greater competition amongst hospitals leads to better quality of care.

Q3 GP competition and quality

Aims

We will test whether greater competition amongst general practices leads to better quality of care for the patients on their lists.

The research question is of policy interest because of policy changes which may affect the degree of competition amongst practices and the importance of general practice in the NHS because of the number of patient-GPs contacts, the health impact of GPs and the gatekeeping role of GPs.

Context and problem statement

Both the health and social care sectors are mixed economies with a range of organisational structures and ownership types. On the supply side, policy in relation to the NHS is for greater market entry by all types of organisation including for-profit providers.

In social care, most mainstream services are commissioned from the private and voluntary sectors. In recent years we have seen greater market penetration by large corporate providers and consolidation in the non-profit sector.

On the demand side we will see even greater organisational change. GP consortia will be established. The role of Local Authorities in health, as well as social care will become greater. There is also the piloting and potential roll out of personal health budgets, in line with the personal budgets in social care.

Project aims

The aim of this project is to establish whether organisation and ownership has a systematic effect on service user outcomes, and in what way.

Context

Despite the vast majority of care being delivered by the market, relatively little is known about turnover of supply, the reasons for turnover, and the wider implications it has for quality and cost. Following the well-publicised demise of Southern Cross – the largest care home group at the time – questions have been raised about the need for greater oversight of the market. In particular, whether existing mechanisms can effectively ensure service continuity within social care, or whether new measures are necessary.

Previous work on care home closures in England has tended to be small-scale studies of homes that have closed. These have found no descriptive relationship between the quality of the home and the likelihood of closure, although (low) price was seen as an important contributory factor. Given the obviously significant implications of home closures and supply-side change, a better understanding of market dynamics appears to be a high priority for research.

Project aims

We aim to undertake four sets of analysis as follows:

• Analysis of the quality, price and type/ownership of providers that exit the market, controlling for local market characteristics e.g. competition, average prices and so on. The aim is to assess whether the price, quality and other characteristics of exiting providers are significantly different from incumbent/continuing providers.
• Analysis of the quality, price and type/ownership of new providers that enter the market (where an inspection has been done and quality information is available), again controlling for local market characteristics. This analysis should tell us whether new providers are differentiated or not from incumbent providers.
• Analysis of the characteristics of the market in which supply-side change (exit and entry) occurs, including levels of competition, locational characteristics, average care home prices and average house prices. The aim is to investigate the degree to which supply-side change is dependent on the characteristics of the local market.
• Assessment of how the quality and prices of incumbent providers change in response to the exit of competing providers in the previous year or the entry of new providers in the current year.
• An assessment of the relative sufficiency of supply in care markets.

Context

The coordination between the health and social care sector is a key policy concern. Coordination is critical because health and social care can be substitutes. For example, hospital discharges can be delayed due to a waiting list in a care home; and higher availability of social care can prevent hospitalisation. However, there is limited empirical evidence which investigates the relationship between health and social care.

Q1 What is the substitution between health and formal care?

Aims

The aim of this project is to estimate the degree of substitution between health and formal social care.

Q2 Does the availability of social care reduce delayed discharge?

Aims

We will test whether higher availability of social care reduces the number and composition of delayed discharges (as reported at local authority and hospital level).