Three Studies in Healthcare Costing and Quality. New evidence from England and Wales on the Impact of the Reference Cost Index and Payment by Result Systems

Alotaibi, Abdullah (2021) Three Studies in Healthcare Costing and Quality. New evidence from England and Wales on the Impact of the Reference Cost Index and Payment by Result Systems. Doctoral thesis, University of East Anglia.

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Healthcare provision accounts for a high proportion of public finances worldwide. Therefore, efficiency, quality and value for money are paramount. This thesis focuses on healthcare resource usage in the National Health Service (NHS), in England and Wales where reforms have long sought to ensure value for money and accountability. However, evaluating healthcare performance is complex. Since 1997, the National Reference Cost Index (NRCI) costing system has been applied to generate reliable data for all NHS clinical treatments and to drive improvements to the system. This thesis encompasses three studies.

Study 1 Contributes to knowledge in the field of healthcare accounting by presenting an updated mapping of RCIs and an examination of trends within the NHS trusts. The study investigated trends and changes to RCIs, trust1 numbers, trust types and variations between the mean RCI of each group (i.e., region, type and foundation status) from the national average. Descriptive statistics were used, from 1997 (the introduction of the Reference Cost system) to
2016: for 1997 to 2009 data were collected from the National Archives of the Department of Health website; data for 2010 to 2016 were collected from the NHS Reference Costs Collection website. Furthermore, the study’s focus is on NHS trusts’ characteristics rather than patient characteristics or productivity which have attracted previous research attention, extending our understanding of healthcare costs, trends, patterns figures and differences between foundation and non-foundation trusts over the various regions and trust types, for the first 20 years of NRCI application.

Study 2 examines cost variations between 2009 and 2016 by analysing the relationship between specific organisational characteristics (i.e., location, the type of service, foundation status and size), which were taken as individual uncontrollable variables, and RCIs. The National Archives of the Department of Health website provided the data for 2009, while NHS Reference Costs Collection website were used for data from 2010 to 2016. Size data was from England NHS website. Patient classification and gender, collected from NHS Digital website, were taken as control variables. Ordinary Least Square (OLS) regression technique was used and cost differences across trusts were identified. The study is distinct from previous work in this field as it focuses on trust characteristics and, to the author’s knowledge, is the first to analyse the associations between combined trust characteristics and RCIs over an extended time period. Furthermore, the study uses data for all HRGs, rather than selecting specific categories, as previous research has done. Study 2 takes contingency theory as its theoretical framework, since it suggests that applying a single cost system for organisations which differ as to their geography, type, size, ownership and technology may not be appropriate and that variations should be taken into account.

Study 3 examines the relationship between RCI reduction and the quality of trust services provided, in the context of the introduction of Payment by Results (PbR) in the NHS to improve the cost efficiency of trust management. The study applied seven quality measures: mortality rates, Same-day Discharge (SDD), infection rates, mean Length of Stay (LOS), emergency and in-patient and out-patient waiting times. Data were collected from three NHS websites for the period 2010 to 2016. Data for RCIs and foundation status were from the NHS Reference Costs Collection website. Data for the dependent and other control variables were extracted from the NHS Digital website and the National Archives of the Department of health. Study 3 uses panel fixed effect regression. This study contributes to the fields of costing and healthcare quality by examining the association between cost and the quality of trust services provided. Study 3 is the first, to the researcher’s knowledge, to use infection rates as a measure of quality, or to evaluate quality while making a distinction between trusts at the upper and lower ends of the RCI scale.

Item Type: Thesis (Doctoral)
Faculty \ School: Faculty of Social Sciences > Norwich Business School
Depositing User: Chris White
Date Deposited: 22 May 2023 10:01
Last Modified: 22 May 2023 10:01

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