Search

Background Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources Quality Outcomes Framework and Secondary Services Use data. Design Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020). Study population and setting Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration This trial is registered as ISRCTN13880272. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

The environment in which we live impacts on our health. The food available to us in our environment is likely to influence what we eat and subsequently our weight. The use of planning policy can be one way for both local and national government to help shape a healthy environment. In England there are three main types of planning policy used to promote a healthy food environment: 1) restricting new fast-food outlets near schools; 2) restricting new fast-food outlets if the density of existing outlets has surpassed a certain threshold of all retail outlets, 3) restricting new fast-food outlets if childhood obesity rates are above a certain threshold. In 2015, Gateshead council, a local authority in the North East of England implemented all three types of guidance. We utilise a longitudinal administrative dataset, the Food Standards Agency Food Hygiene Rating Scheme Data, covering the period 2012-2019 on all premises selling or preparing food in Great Britain. To analyse the impact of employing all three types of planning guidance on the density, proportion, and number of fast-food outlets in Gateshead, we employ a propensity score matching difference-in-difference approach. We match small geographical areas in Gateshead (lower super output areas) to other local authorities in the North East with similar demographic characteristics that did not implement planning guidance. Results show a reduction in density of fast-food outlets by 12.45 per 100,000 of the population and a 13.88% decrease in the proportion of fast-food outlets in Gateshead compared to other similar local authorities in the North East. There was a marginally significant reduction in the number of restaurants which became insignificant after controlling for population density. These results suggest that a multi-pronged planning approach significantly changed the proportion and density of fast-food outlets in the food environment in the short term (4 years).

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

Introduction Willingness to pay (WTP) is used to generate information about value. However, when comparing 2 or more services using standard WTP techniques, the amounts elicited from participants for the services are often similar, even when individuals state a clear preference for one service over another. An incremental approach has been suggested, in which individuals are asked to first rank interventions and provide a WTP value for their lowest-ranked intervention followed by then asking how much more they are willing to pay for their next preferred choice and so on. To date, evaluation of this approach has disregarded protest responses, which may give information on consistency between stated and implicit rankings. Methods A representative sample of the English population ( n = 790) were asked to value 5 dental services adopting a societal perspective, using a payment vehicle of additional household taxation per year. The sample was randomized to either the standard or the incremental approach. Performance for both methods is assessed on discrimination between values for interventions and consistency between implicit and stated ranks. The data analysis is the first to retain protest responses when considering consistency between ranks. Results The results indicate that neither approach provides values that discriminate between interventions. Retaining protest responses reveals inconsistencies between the stated and implicit ranks are present in both approaches but much reduced in the incremental approach. Conclusion The incremental approach does not improve discrimination between values, yet there is less inconsistency between ranks. The protest responses indicate that objections to giving values to the dental interventions are dependent on a multitude of factors beyond the elicitation process.

ObjectiveTo determine the association between income inequality and COVID-19 cases and deaths per million in OECD countries.MethodsCross-sectional regression methods are used to model the relationship between income inequality, as measured by the Gini coefficient, and COVID-19 reported cases and deaths per-million.ResultsThe results demonstrate a significant positive association between income inequality and COVID-19 cases and death per million in all estimated models. A 1% increase in the Gini coefficient is associated with an approximately 4% increase in cases per-million and an approximately 5% increase in deaths per-million.ConclusionsThe results demonstrate that countries with high levels of income inequality have performed significantly worse when dealing with the COVID-19 outbreak in terms cases and deaths. Income inequality is a proxy for many elements of socioeconomic disadvantage that may contribute to the spread of, and deaths from, COVID-19. These include poor housing, smoking, obesity and pollution.Policy ImplicationsThe findings suggest the importance of closing the gap in income inequality and improving the health and incomes of the poorest and most vulnerable groups.

Healthcare systems in many countries are enthusiastically adopting link worker social prescribing interventions that aim to tackle the social determinants of health by linking patients to voluntary and community sector activities and sources of support to address their social needs and improve condition management. Social prescribing interventions aim to improve health and reduce healthcare spending. However, despite the diversion of healthcare budgets to fund social prescribing, we still lack robust evidence for its effectiveness. In this study we evaluate whether participation in a social prescribing intervention reduced non-elective admitted patient care use and costs for 8283 patients aged between 40 and 74 years, with a diagnosis of type 2 diabetes and living in an area of high socioeconomic deprivation in north-east England. Patients were followed for a total of 6 years: 2 years pre-intervention and 4 years post intervention. Exploiting a natural experiment, we used a two-part difference-in-differences regression model to estimate costs conditional on healthcare use. We also estimated intervention effects across several intervention and control groups and sample subgroups. Participation in the intervention resulted in reductions of up to -£77.57 [95% CI: -152.30, -2.84] (for high engagement patients) per patient, per year, in non-elective care costs. Reductions were greater for patients with higher levels of engagement with the intervention. Sub-group analyses showed greater cost reductions for non-White patients, older patients, and patients without additional co-morbidities. Our findings suggest that engagement with a link worker social prescribing intervention may reduce non-elective healthcare spending, perhaps through enabling better condition management that results in fewer avoidable health crises.

We study the link between the revelation of a hitherto non-existent occupational risk - mortality due to the COVID-19 pandemic in 2020 - and subsequent worker behaviour. We link occupation-specific data on COVID-19 mortality to individual level data sets. We find that wages did not adjust, but workers started leaving high-risk occupations during 2020. These effects are stronger for workers not affected by lockdowns or working from home orders and for those considered to be clinically vulnerable to COVID-19 and are not driven by negative health shocks or employer-initiated separations. Occupation-level results suggest that employment began to rebound in 2021.

Opposition to Universal Basic Income (UBI) is encapsulated by Martinelli’s claim that ‘an affordable basic income would be inadequate, and an adequate basic income would be unaffordable’. In this article, we present a model of health impact that transforms that assumption. We argue that UBI can affect higher level social determinants of health down to individual determinants of health and on to improvements in public health that lead to a number of economic returns on investment. Given that no trial has been designed and deployed with that impact in mind, we present a methodological framework for assessing prospective costs and returns on investment through modelling to make the case for that trial. We begin by outlining the pathways to health in our model of change in order to present criteria for establishing the size of transfer capable of promoting health. We then consider approaches to calculating cost in a UK context to estimate budgetary burdens that need to be met by the state. Next, we suggest means of modelling the prospective impact of UBI on health before asserting means of costing that impact, using a microsimulation approach. We then outline a set of fiscal options for funding any shortfall in returns. Finally, we suggest that fiscal strategy can be designed specifically with health impact in mind by modelling the impact of reform on health and feeding that data cyclically back into tax transfer module of the microsimulation.

Introduction: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. Methods: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. Results: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. Discussion: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. Knowledge Transfer Statement: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

BackgroundWhile inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland.MethodsUsing nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways.ResultsLower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, −0.21 (SE=0.01) and −0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects.ConclusionReducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

In this journal there has been considerable discussion regarding the development of tools for valuing the multiple attributes that arise from complex interventions with benefits beyond health. Nevertheless, unlike the rigorous underpinnings of cost-utility analysis, much of this work has been taking place in fragmented research communities and without theoretical underpinnings, leading to a call for better and more comprehensive frameworks. We discuss the challenges faced by economic evaluation using as our example a "social prescribing" intervention, a novel health intervention based on the social model of health. We suggest a mixed-methods approach to uncover important attributes and then combine tools from health economics and economics to provide measures of benefit in a common money numeraire. This approach provides the theoretical underpinnings necessary for deliberate, transparent, and structured decision-making processes. It also enables the correct allocation of costs within complex payment systems. We suggest that, because of the complexities of randomized controlled trials, interventions should be introduced in a way that allows the application of causal analysis for evaluation. In the short term, such evaluations may be challenging and expensive. Nevertheless, as has happened with health economics evaluation and the quality-adjusted life-year, when a common set of attributes is agreed upon, the expense will fall and these methods can become embedded in interventions with diffuse outcomes.

Key Points Question Is a community health worker social prescribing program associated with improved glycemic control among UK patients aged 40 to 74 years with type 2 diabetes? Findings In this cohort study with difference-in-differences analysis of 8086 patients in the UK National Health System, a holistic community health worker intervention was associated with improvements in hemoglobin A1c levels. The association increased over time and was greater for White patients vs non-White patients, those with fewer additional comorbidities, and those living in the most socioeconomically deprived areas. Meaning The community health worker social prescribing program was associated with improved glycemic control, suggesting that these types of interventions may help to reduce the public health burden of type 2 diabetes., This cohort study examines whether a UK National Health Service community health worker social prescribing program was associated with improved hemoglobin A1c levels among patients with type 2 diabetes, Importance Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care. Objective To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes. Design, Setting, and Participants This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021. Interventions A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city’s west. The control group included patients in the city’s east where referral was unavailable. Main Outcomes and Measures HbA1c level, a marker of glycemic control. Results A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of −0.10 percentage points (95% CI, −0.17 to −0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was −0.14 percentage points (95% CI, −0.24 to −0.03 percentage points). The association was stronger for White patients compared with non-White patients (−0.15 percentage points [95% CI, −0.26 to −0.04 percentage points] after 3 years), those with fewer additional comorbidities (−0.16 percentage points [95% CI, −0.29 to −0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (−0.19 percentage points [95% CI, −0.32 to −0.07 percentage points] after 3 years). Conclusions and Relevance In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients’ social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

IntroductionSocial prescribing enables healthcare professionals to use voluntary and community sector resources to improve support for people with long-term conditions. It is widely promoted in the UK as a way to address complex health, psychological and social issues presented in primary care, yet there is insufficient evidence of effectiveness or value for money. This study aims to evaluate the impact and costs of a link-worker social prescribing intervention on the health and healthcare use of adults aged 40–74 with type 2 diabetes, living in a multi-ethnic area of high socioeconomic deprivation.Methods and analysisMixed-methods approach combining (1) quantitative quasi-experimental methods to evaluate the effects of social prescribing on health and healthcare use and cost-effectiveness analysis and (2) qualitative ethnographic methods to observe how patients engage with social prescribing. Quantitative data comprise Secondary Uses Service data and Quality Outcomes Framework data. The primary outcome is glycated haemoglobin, and secondary outcomes are secondary care use, systolic blood pressure, weight/body mass index, cholesterol and smoking status; these data will be analysed longitudinally over 3 years using four different control conditions to estimate a range of treatment effects. The ranges where the intervention is cost-effective will be identified from the perspective of the healthcare provider. Qualitative data comprise participant observation and interviews with purposively sampled service users, and focus groups with link-workers (intervention providers). Analysis will involve identification of themes and synthesising and theorising the data. Finally, a coding matrix will identify convergence and divergence among all study components.Ethics and disseminationUK NHS Integrated Research Approval System Ethics approved the quantitative research (Reference no. 18/LO/0631). Durham University Research Ethics Committee approved the qualitative research. The authors will publish the findings in peer-reviewed journals and disseminate to practitioners, service users and commissioners via a number of channels including professional and patient networks, conferences and social media. Results will be disseminated via peer-reviewed journals.

Using an equilibrium model of inter-linked frictional labour and marriage markets, we establish the existence of male marriage premium within a given productivity group, as well as a clear ranking of premia across different groups. We find supporting evidence using Chinese data.

Background Resources in any healthcare systems are scarce relative to need and therefore choices need to be made which often involve difficult decisions about the best allocation of these resources. One pragmatic and robust tool to aid resource allocation is Programme Budgeting and Marginal Analysis (PBMA), but there is mixed evidence on its uptake and effectiveness. Furthermore, there is also no evidence on the incorporation of the preferences of a large and representative sample of the general public into such a process. The study therefore aims to undertake, evaluate and refine a PBMA process within the exemplar of NHS dentistry in England whilst also using an established methodology (Willingness to Pay (WTP)) to systematically gather views from a representative sample of the public. Methods Stakeholders including service buyers (commissioners), dentists, dental public health representatives and patient representatives will be recruited to participate in a PBMA process involving defining current spend, agreeing criteria to judge services/interventions, defining areas for investment and disinvestment, rating these areas against the criteria and making final recommendations. The process will be refined based on participatory action research principles and evaluated through semi-structured interviews, focus groups and observation of the process by the research team. In parallel a representative sample of English adults will be recruited to complete a series of four surveys including WTP valuations of programmes being considered by the PBMA panel. In addition a methodological experiment comparing two ways of eliciting WTP will be undertaken. Discussion The project will allow the PBMA process and particularly the use of WTP within it to be investigated and developed. There will be challenges around engagement with the task by the panel undertaking it and with the outputs by stakeholders but careful relationship building will help to mitigate this. The large volume of data will be managed through careful segmenting of the analysis and the use of the well-established Framework approach to qualitative data analysis. WTP has various potential biases but the elicitation will be carefully designed to minimise these and some methodological investigation will take place. Electronic supplementary material The online version of this article (10.1186/s12913-018-3302-8) contains supplementary material, which is available to authorized users.

Summary We consider two econometric problems when investigating the effect of family size on labour market outcomes using the popular twin birth instrument. The first is the potential for omitted variable bias caused by the fact that fertility treatments are linked to twin births and are typically unobserved. We present estimates that are corrected for this bias and find that it is comparatively small. Second, we show that the effects of twin-birth-induced variation in family size, as well as characteristics of the compliers, varies substantially with time passed since birth, which has consequences for the interpretation of estimates across samples and time.

Oral health inequalities associated with socioeconomic status are widely observed but may depend on the way that both oral health and socioeconomic status are measured. Our aim was to investigate inequalities using diverse indicators of oral health and 4 socioeconomic determinants, in the context of age and cohort. Multiple linear or logistic regressions were estimated for 7 oral health measures representing very different outcomes (2 caries prevalence measures, decayed/missing/filled teeth, 6-mm pockets, number of teeth, anterior spaces, and excellent oral health) against 4 socioeconomic measures (income, education, Index of Multiple Deprivation, and occupational social class) for adults aged ≥21 y in the 2009 UK Adult Dental Health Survey data set. Confounders were adjusted and marginal effects calculated. The results showed highly variable relationships for the different combinations of variables and that age group was critical, with different relationships at different ages. There were significant income inequalities in caries prevalence in the youngest age group, marginal effects of 0.10 to 0.18, representing a 10- to 18-percentage point increase in the probability of caries between the wealthiest and every other quintile, but there was not a clear gradient across the quintiles. With number of teeth as an outcome, there were significant income gradients after adjustment in older groups, up to 4.5 teeth (95% confidence interval, 2.2-6.8) between richest and poorest but none for the younger groups. For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces, the relationships were age dependent and complex. In conclusion, oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory. Appropriate choices of measures in relation to age are fundamental if we are to understand and address inequalities.

Background and Purpose— Analyses of trends in the delivery of time critical treatments typically report the median, but measures of central tendency may ignore important changes for specific patient groups. We considered whether this was an important effect during comparison of onset to treatment (OTT) time between 2 cohorts of patients with stroke receiving intravenous thrombolysis. Methods— After controlling for stroke severity, a relative distributions technique compared OTT for UK patients treated with recombinant tissue-type plasminogen activator registered within the first and last quarters (each n=661) of the Safe Implementation of Thrombolysis in Stroke-Monitoring Study database between January 2003 and September 2010. Results— Significant differences were found between OTT distributions. Overall, the second cohort’s OTT distribution demonstrated simultaneous increases in the proportion of patients with faster and slower OTT, which resulted in no net effect on the median after correction for stroke severity. Conclusions— Medians did not adequately describe distributional changes. Faster OTT may be because of more efficient processes in acute stroke centers and improved symptom recognition by the public. Slower OTT is likely to reflect movement from a 3- to a 4.5-hour OTT target. Relative distributions offer new insights into historical trends and service evaluation where time critical treatments are involved.

The appropriate thresholds for decisions on the cost-effectiveness of medical interventions remain controversial, especially in 'end-of-life' situations. Evidence of the values placed on different types of health gain by the general public is limited. Across nine European countries, 17 657 people were presented with different hypothetical health scenarios each involving a gain of one quality adjusted life year (QALY) and asked about their willingness to pay (WTP) for that gain. The questions included quality of life (QoL) enhancing and life extending health gains, and a scenario where respondents faced imminent, premature death. The mean WTP values for a one-QALY gain composed of QoL improvements were modest (PPP$11 000). When comparing QALY gains obtained in the near future, the valuation of life extension exceeded the valuation of QoL enhancing gains (mean WTP PPP$19 000 for a scenario in which a coma is avoided). The mean WTP values were higher still when respondents faced imminent, premature death (PPP$29 000). Evidence from the largest survey on the value of health gains by the general public indicated a higher value for life extending gains compared with QoL enhancing gains. A further modest premium may be indicated for life extension when facing imminent, premature death. Copyright © 2013 John Wiley & Sons, Ltd.

Objectives: With health inequalities high on the policy agenda, this study measures oral health inequalities in the UK. Methods: We compare an objective clinical measure of oral health (number of natural teeth) with a self- reported measure of the impact of oral health (the Oral Health Impact Profile, OHIP) to establish whether the type of measure affects the scale of inequality measured. Gini coefficients and Concentration Indices (CIs) are calculated with subsequent decompositions using data from the 1998 UK Adult Dental Health Survey. Because the information on OHIP is only available on dentate individuals, analyses on the number of natural teeth are conducted for two samples - the entire sample and the sample with dentate individuals only, the latter to allow direct comparison with OHIP. Results: We find considerable overall pure oral health inequalities (number of teeth: Gini = 0.68 (including edentate), Gini = 0.40 (excluding edentate); OHIP: Gini = 0.33) and income- related inequalities for both measures (number of teeth: CI = 0.35 (including edentate), CI = 0.15 (excluding edentate); OHIP: CI = 0.03), and the CI is generally higher for the number of teeth than for OHIP. There are differences across age groups, with CI increasing with age for the number of teeth (excluding edentate: 16-30 years: CI = 0.01, 65 + years: CI = 0.11; including edentate: 16-30 years: CI = 0.01, 65 + years: CI = 0.19). However, inequalities for OHIP were highest in the youngest age group (CI = 0.05). Number of teeth reflects the accumulation of damage over a lifetime, while OHIP records more immediate concerns. Conclusions: There are considerable pure oral health inequalities and income-related oral health inequalities in the UK. Using sophisticated methods to measure oral health inequality, we have been able to compare inequality in oral health with inequality in general health. The results provide a benchmark for future comparisons but also indicate that the type of health measure may be of considerable significance in how we think about and measure oral health inequalities.

The elicitation of societal views about healthcare priority setting is an important, contemporary research area, and there are a number of studies that apply either qualitative techniques or quantitative preference elicitation methods. However, there are methodological challenges in connecting qualitative information (what perspectives exist about a subject) with quantitative questions (to what extent are those perspectives ‘supported’ in a wider population). In this paper, we present an integrated, mixed-methods approach to the elicitation of public perspectives in two linked studies applying Q methodology. In the first study, we identify three broad viewpoints on the subject of health priorities. In the second study, using Q-survey methods, we describe and illustrate methods to investigate the distribution of those views in the wider population. The findings of the second study suggest that no single viewpoint dominates and none of the three views represents a ‘minority perspective’. We demonstrate the potential of Q methodology as a methodological framework that can be used to link qualitative and quantitative questions and suggest some advantages of this over other approaches. However, as this represents the first applied study of this kind, there are methodological questions that require further exploration and development. Copyright © 2013 John Wiley & Sons, Ltd.

Using the UK Citizenship Survey for the years 2007–2010, this paper investigates how immigrants view immigration and how these views compare to the views of natives. Immigrants who have been in the UK longer are similar to natives in being opposed to further immigration, while recent immigrants are more in favour of further immigration. Labour market concerns do not play a large role for either immigrants or natives. However, there is some evidence that financial and economic shocks can increase anti-immigration sentiments.

We propose a theoretical explanation for the so-called "beauty premium". Our approach relies entirely on search frictions and the fact that physical appearance plays an important role in attracting a marriage partner. We analyse the interaction between frictional labour and marriage markets, making use of what we label constrained job search. The optimal strategy entails different reservation wages for different men, and we establish the existence of a search equilibrium characterised by beauty premium and/or marriage premium. Predicted profiles of premia allow for potential falsification tests and point to relevant empirical evidence in support of our theory.

Smoking bans in public places are considered an important public health intervention. The impact of such bans on health, and especially self-reported health, has not been widely considered in the literature. This paper investigates the impact of a public smoking ban on self-reported health status in Great Britain. We find that there are benefits for non-smoking women, but no benefits for smokers.

With an ageing population there is a move towards the use of assisted living technologies (ALTs) to provide social care and health care services, and to improve service processes. These technologies are at the forefront of the integration of health and social care. However, economic evaluations of ALTs, and indeed economic evaluations of any interventions providing both health benefits and benefits beyond health are complex. This paper considers the challenges faced by evaluators and presents a method of economic evaluation for use with interventions where traditional methods may not be suitable for informing funders and decision makers. We propose a method, combining economic evaluation techniques, that can accommodate health outcomes and outcomes beyond health through the use of a common numeraire. Such economic evaluations can benefit both the public and private sector, firstly by ensuring the efficient allocation of resources. And secondly, by providing information for individuals who, in the market for ALTs, face consumption decisions that are infrequent and for which there may be no other sources of information. We consider these issues in the welfarist, extra-welfarist and capabilities frameworks, which we link to attributes in an individual production model. This approach allows for the valuation of the health component of any such intervention and the valuation of key social care attributes and processes. Finally, we present a set of considerations for evaluators highlighting the key issues that need to be considered in this type of economic evaluation.

Governments across Europe are required to make decisions about how best to allocate scarce health care resources. There are legitimate arguments for eliciting societal vales in relation to health care resource allocation given the roles of the general public as payers and potential patients. However, relatively little is known about the views of the general public on general principles which could guide these decisions. In this paper we present five societal viewpoints on principles for health care resources allocation and develop a new approach, Q2S, designed to investigate the extent to which these views are held across a range of European countries. An online survey was developed, based on a previously completed study Q methodology, and delivered between November 2009 and February 2010 across nine countries to 33,515 respondents. The largest proportion of our respondents (44%), were found to most associate themselves with an egalitarian perspective. Differences in views were more strongly associated with countries than with socio-demographic characteristics. These results provide information which could be useful for decision makers in understanding the pluralistic context in which they are making health care resource allocation decisions and how different groups in society may respond to such decisions.

This paper presents the first attempt to use a discrete choice experiment to derive distributional weights for quality adjusted life years (QALYs), based on characteristics (age and severity) of the beneficiaries. A novel approach using the Hicksian compensating variation is applied. Advantages include derivation of weights for QALYs, not just for life or life years saved, and investigation of the impact of the size of the health gain by allowing the gain to be traded against other characteristics. Results suggest one would generally not weight QALYs, except in a small number of specific cases and in those cases the weights are relatively small. Methodological challenges are highlighted as is a future research agenda.

It is believed that income affects health directly but it is argued that indirect income effects due to relative deprivation may be equally important. This paper investigates these relationships using parametric and semiparametric panel data models which ameliorate problems of mis-specification and unobservable heterogeneity. By allowing for a flexible functional form of income we ensure that coefficients on relative deprivation variables are not an artefact of a highly non-linear relationship between health and income. The results provide strong evidence for the impact of income on self-reported measures of health for men and women. These results are robust across a range of techniques and are resilient to the inclusion of measures of relative deprivation. The parametric results for relative deprivation largely reject its influence on health, although there is some evidence of an effect in the semiparametric models.

Attempts to test the relative deprivation hypothesis, that income inequality affects individual health, are subject to the aggregation problem. Waldmann (Quarterly Journal of Economics 107, 1992) ingeniously attempts to overcome the difficulty by using income data for the poor and the share of income accruing to the rich. The study finds that his results do not hold for a more recent data set and it suggests that his method may not overcome the aggregation problem.

The World Health Organisation's (WHO) approach to the measurement of health system efficiency is briefly described. Four arguments are then presented. First, equity of finance should not be a criterion for the evaluation of a health system and, more generally, the same objectives and importance weights should not be imposed upon all countries. Secondly, the numerical value of the importance weights do not reflect their true importance in the country rankings. Thirdly, the model for combining the different objectives into a single index of system performance is problematical and alternative models are shown to alter system rankings. The WHO statistical analysis is replicated and used to support the fourth argument which is that, contrary to the author's assertion, their methods cannot separate true inefficiency from random error. The procedure is also subject to omitted variable bias. The econometric model for all countries has very poor predictive power for the subset of OECD countries and it is outperformed by two simpler algorithms. Country rankings based upon the model are correspondingly unreliable. It is concluded that, despite these problems, the study is a landmark in the evolution of system evaluation, but one which requires significant revision.

The World Health Report 2000 focuses on the performance of health-care systems around the globe. The report uses efficiency measurement techniques to create a league table of health-care systems, highlighting good and bad performers. Efficiency is measured using panel data methods. This paper suggests that the WHO's estimation procedure is too narrow and that contextual information is hidden by the use of one method. This paper uses and validates a range of parametric and non-parametric empirical methods to measure efficiency using the WHO data. The rankings obtained are compared to the WHO league table and we demonstrate that there are trends and movements of interest within the league tables. We recommend that the WHO broaden its range of techniques in order to reveal this hidden information. Copyright © 2002 John Wiley & Sons, Ltd.

Objectives Determining the value of, or strength of preference for health care interventions is useful for policy makers in planning health care services. Willingness to pay (WTP) is an established economic technique to determine the strength of preferences for interventions by eliciting monetary valuations from individuals in hypothetical situations. The objective of this study was to elicit WTP values for a dental preventive intervention and to analyze the factors affecting these as well as investigating the validity of the WTP method. Methods Patients aged 40 years plus attending dental practices in the UK and Germany were recruited on a consecutive basis over one month. Participants received information about a novel root caries prevention intervention. They then completed a questionnaire including a WTP task. Where the coating was indicated, patients were offered this for a payment and acceptance was recorded. Analysis included econometric modelling and comparison of expected (based on stated WTP) versus actual behaviour. Results The mean WTP for the coating was £96.41 (standard deviation 60.61). Econometric models showed that no demographic or dental history factors were significant predictors of WTP. 63% of the sample behaved as expected when using stated WTP to predict whether they would buy the coating. The remainder were split almost equally between those expected to pay but who did not and those who were expected to refuse but paid. Conclusions Values for a caries preventive intervention had a large and unpredictable variance. In comparing hypothetical versus real preferences both under- and over-valuation occurs. Clinical significance Wide and unpredictable variation in valuations for prevention may mean that there are difficult policy questions around what resource should be allocated to dental prevention and how to target this resource.

Background Oral diseases are highly prevalent and impact on oral health-related quality of life (OHRQoL). However, time changes in OHRQoL have been scarcely investigated in the current context of general improvement in clinical oral health. This study aims to examine changes in OHRQoL between 1998 and 2009 among adults in England, and to analyse the contribution of demographics, socioeconomic characteristics and clinical oral health measures. Methods Using data from two nationally representative surveys in England, we assessed changes in the Oral Health Impact Profile-14 (OHIP-14), in both the sample overall (n=12 027) and by quasi-cohorts. We calculated the prevalence and extent of oral impacts and summary OHIP-14 scores. An Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographics (age, gender, marital status), socioeconomic position (education, occupation) and clinical measures (presence of decay, number of missing teeth, having advanced periodontitis). Results There were significant improvements in OHRQoL, predominantly among those that experienced oral impacts occasionally, but no difference in the proportion with frequent oral impacts. The decomposition model showed that 43% (–4.07/–9.47) of the decrease in prevalence of oral impacts reported occasionally or more often was accounted by the model explanatory variables. Improvements in clinical oral health and the effect of ageing itself accounted for most of the explained change in OHRQoL, but the effect of these factors varied substantially across the lifecourse and quasi-cohorts. Conclusions These decomposition findings indicate that broader determinants could be primarily targeted to influence OHRQoL in different age groups or across different adult cohorts.

Twin births are often used to instrument for fertility when investigating the impact of family size on labor market outcomes. In this paper we consider two econometric problems both related to the link between fertility treatments and multiple births. The first is the potential for omitted variable bias caused by the fact that fertility treatments are typically unobserved. We present estimates corrected for this bias and find it to be comparatively small. Second, we show that the effects of twin-birth induced variation in family size vary substantially with time passed since birth, which has consequences for the interpretation of estimates based on a single cross-section.

Aim To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem. Methodology A total of 503 patients were recruited from dental practices in the North East of England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction and various prosthetic restorative options) and WTP for this preferred option were elicited. Factors affecting preferred option and WTP were analysed using econometric modelling. Results Overall, 53% of the sample wished to save the tooth with a mean WTP of £373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income. Conclusions The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policy makers trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policy making.

The elicitation of societal views about healthcare priority setting is an important, contemporary research area, and there are a number of studies that apply either qualitative techniques or quantitative preference elicitation methods. However, there are methodological challenges in connecting qualitative information (what perspectives exist about a subject) with quantitative questions (to what extent are those perspectives 'supported' in a wider population). In this paper, we present an integrated, mixed-methods approach to the elicitation of public perspectives in two linked studies applying Q methodology. In the first study, we identify three broad viewpoints on the subject of health priorities. In the second study, using Q-survey methods, we describe and illustrate methods to investigate the distribution of those views in the wider population. The findings of the second study suggest that no single viewpoint dominates and none of the three views represents a 'minority perspective'. We demonstrate the potential of Q methodology as a methodological framework that can be used to link qualitative and quantitative questions and suggest some advantages of this over other approaches. However, as this represents the first applied study of this kind, there are methodological questions that require further exploration and development.

Recently, for many health economics researchers, empirical estimation of the monetary valuation of a quality-adjusted life year (QALY) has become an important endeavour. Different philosophical and practical approaches to this have emerged. On the one hand, there is a view that, with health-care budgets set centrally, decision-making bodies within the system can iterate, from observation of a series of previous decisions, towards the value of a QALY, thus searching for such a value. Alternatively, and more consistent with the approach taken in other public sectors, individual members of the public are surveyed with the aim of directly eliciting a preference-based – also known as a willingness-to-pay-based (WTP-based) – value of a QALY. While the former is based on supply-side factors and the latter on demand, both in fact suffer from informational deficiencies. Sole reliance on either would necessitate an acceptance or accommodation of chronic inefficiencies in health-care resource allocation. On the basis of this observation, this paper makes the case that in order to approach optimal decision making in health-care provision, a framework incorporating and thus, to a degree, reconciling these two approaches is to be preferred.

Background: Since the inception of the National Institute for Health and Clinical Excellence (NICE) in England,\ud there have been questions about the empirical basis for the cost-per-QALY threshold used by NICE and whether\ud QALYs gained by different beneficiaries of health care should be weighted equally. The Social Value of a QALY\ud (SVQ) project, reported in this paper, was commissioned to address these two questions. The results of SVQ were\ud released during a time of considerable debate about the NICE threshold, and authors with differing perspectives\ud have drawn on the SVQ results to support their cases. As these discussions continue, and given the selective use of\ud results by those involved, it is important, therefore, not only to present a summary overview of SVQ, but also for\ud those who conducted the research to contribute to the debate as to its implications for NICE.\ud Discussion: The issue of the threshold was addressed in two ways: first, by combining, via a set of models, the\ud current UK Value of a Prevented Fatality (used in transport policy) with data on fatality age, life expectancy and\ud age-related quality of life; and, second, via a survey designed to test the feasibility of combining respondents’\ud answers to willingness to pay and health state utility questions to arrive at values of a QALY. Modelling resulted in\ud values of £10,000-£70,000 per QALY. Via survey research, most methods of aggregating the data resulted in values\ud of a QALY of £18,000-£40,000, although others resulted in implausibly high values. An additional survey, addressing\ud the issue of weighting QALYs, used two methods, one indicating that QALYs should not be weighted and the\ud other that greater weight could be given to QALYs gained by some groups.\ud Summary: Although we conducted only a feasibility study and a modelling exercise, neither present compelling\ud evidence for moving the NICE threshold up or down. Some preliminary evidence would indicate it could be\ud moved up for some types of QALY and down for others. While many members of the public appear to be open to\ud the possibility of using somewhat different QALY weights for different groups of beneficiaries, we do not yet have\ud any secure evidence base for introducing such a system.

To identify characteristics of beneficiaries of health care over which relative weights should be derived and to estimate relative weights to be attached to health gains according to characteristics of recipients of these gains (relativities study); and to assess the feasibility of estimating a willingness-to-pay (WTP)-based value of a quality-adjusted life-year (QALY) (valuation study).Two interview-based surveys were administered - one (for the relativities study) to a nationally representative sample of the population in England and the other (for the valuation study) to a smaller convenience sample.The two surveys were administered by the National Centre for Social Research (NatCen) in respondents' homes.587 members of the public were interviewed for the relativities study and 409 for the valuation study.In the relativities study, in-depth qualitative work and considerations of policy relevance resulted in the identification of age and severity of illness as relevant characteristics. Scenarios reflecting these, along with additional components reflecting gains in QALYs, were presented to respondents in a series of pairwise choices using two types of question: discrete choice and matching. These questions were part of a longer questionnaire (including attitudinal and sociodemographic questions), which was administered face to face using a computer-assisted personal interview. In the valuation study, respondents were asked about their WTP to avoid/prevent different durations of headache or stomach illness and to value these states on a scale (death = 0; full health = 1) using standard gamble (SG) questions.Discrete choice results showed that age and severity variables did not have a strong impact on respondents' choices over and above the health (QALY) gains presented. In contrast, matching showed age and severity impacts to be strong: depending on method of aggregation, gains to some groups were weighted three to four times more highly than gains to others. Results from the WTP and SG questions were combined in different ways to arrive at values of a QALY. These vary from values which are in the vicinity of the current National Institute for Health and Clinical Excellence (NICE) threshold to extremely high values.With respect to relative weights, more research is required to explore methodological differences with respect to age and severity weighting. On valuation, there are particular issues concerning the extent to which 'noise' and 'error' in people's responses might generate extreme and unreliable figures. Methods of aggregation and measures of central tendency were issues in both weighting and valuation procedures and require further exploration.

Approximately 10% of people have O-negative blood. Because it can be transfused into almost anyone, hospitals particularly value such blood. We use this fact, together with the assumption that blood types are exogenously assigned by nature, to design an empirical inquiry into altruism. We also investigate the timing of donations, especially focussing on the behaviour of new and established donors. We show that O-negative blood donors donate no more often than other people. Thus individuals apparently do not exhibit pure altruism. We speculate that instead blood donors may be driven by a broad notion of duty rather than by a far-sighted, rational unselfishness.