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Health system interventions can close access gaps for these vulnerable groups and address inequities in access to care. However, groups like mentally ill, homeless, frail elderly, undocumented migrants are more likely to face multiple layers of exclusion and complex barriers to access. Within the diversity of country cases found in the survey, the most significant barriers for accessing health care still seem to be associated with social and income status, rather than specific medical conditions. The survey was sent to country contacts from the Health Systems and Policy Monitor network. In addition, access can also be hampered by other factors, which relate more to the physical availability of care, a person's ability to obtain necessary care or the attitude of the provider. To explore these gaps more systematically a survey was developed based on the so-called cube model that comprises different dimensions determining health coverage, including population coverage, service coverage and cost coverage. Importantly, this study could not adjust for changes in the quality of care.Īt the request of the European Commission, the Observatory on Health Systems and Policies and the HSPM network have undertaken a study to explore gaps in universal health coverage in the European Union and increase the level of granularity in terms of areas or groups where accessibility is sub-optimal. Increases in the proportions of small purchasers were associated with increasing costs. Hospitals may have chosen to become trusts because they anticipated being able to increase productivity. Market concentration was not associated with productivity differences.įurther analysis is needed to determine whether overall and trust associated productivity gains are transient effects, one off shifts, or self perpetuating reorientations of organisational behaviour.
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Hospitals that became trusts during the study period were on average less productive at the beginning of the period than those that did not, and there were no significant productivity differences between trust waves at the end of the period in 1993-4. Gaining trust status and increasing host district purchaser share were associated with productivity increases after adjustment for casemix, regional salary differences, and hospital size and scope. Casemix adjustment drastically improved cross sectional comparisons between hospitals. Real productivity gains were apparent across the study period for NHS hospitals on average. Cross sectional and longitudinal regression methods were used to estimate the effect of trust status, competition, and purchaser mix on average hospital costs per inpatient, after adjusting for outpatient activity levels, casemix, teaching activity, regional salary variation, hospital size, scale of activity, and scope of cases treated. Hospital cost and activity data were taken from routinely collected data for acute NHS hospitals in England for 1991-2 to 1993-4. To evaluate the effect of purchaser mix, market competition, and trust status on hospital productivity within the NHS internal market.