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ObjectiveTo examine the impact of nursing team size and composition on inpatient hospital mortality.DesignA retrospective longitudinal study using linked nursing staff rostering and patient data. Multilevel conditional logistic regression models with adjustment for patient characteristics, day and time-invariant ward differences estimated the association between inpatient mortality and staffing at the ward-day level. Two staffing measures were constructed: the fraction of target hours worked (fill-rate) and the absolute difference from target hours.SettingThree hospitals within a single National Health Service Trust in England.Participants19 287 ward-day observations with information on 4498 nurses and 66 923 hospital admissions in 53 inpatient hospital wards for acutely ill adult patients for calendar year 2017.Main outcome measureIn-hospital deaths.ResultsA statistically significant association between the fill-rate for registered nurses (RNs) and inpatient mortality (OR 0.9883, 95% CI 0.9773 to 0.9996, p=0.0416) was found only for RNs hospital employees. There was no association for healthcare support workers (HCSWs) or agency workers. On average, an extra 12-hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6% (OR 0.9044, 95% CI 0.8219 to 0.9966, p=0.0416). An additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (fill-rate for bands 7 and 8: OR 0.9760, 95% CI 0.9551 to 0.9973, p=0.0275; band 5: OR 0.9893, 95% CI 0.9771 to 1.0017, p=0.0907).ConclusionsRN staffing and seniority levels were associated with patient mortality. The lack of association for HCSWs and agency nurses indicates they are not effective substitutes for RNs who regularly work on the ward.

Policy Points US policymakers considering proposals to expand public health care (such as "Medicare for all") as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well-funded universal health care systems are already in place. In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity. Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. Context Expanding access to health care is once again high on the US political agenda, as is concern about those who are being "left behind." But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education-level-defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use. Methods Novel linkage of data from six waves (2004-2015) of the English Longitudinal Study of Ageing (ELSA) with participants' hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004-2005 to 2008-2009 and 2010-2011 to 2014-2015 to examine whether potential education-related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010. Findings For the study period, our sample of ELSA respondents in the low-education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high-education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11-0.47). Additional outpatient health care use in the high-education group was driven by follow-up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high-education group made 0.48 (95% CI, 0.21-0.74) more annual outpatient visits than those in the low-education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high-education group made 0.04 (95% CI, -0.075 to 0.001) fewer annual ED visits than the low-education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period. Conclusions After controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high-education group using more outpatient care and less ED care than peers in the low-education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

This paper examines the impact of changes in public long-term care spending on the use of public hospitals among the older population in England. Mean per-person long-term care spending fell by 31% between 2009/10 and 2017/18, but cuts varied considerably geographically. We instrument public long-term care spending with predicted spending based on historical national funding shares and national spending trends. We find that reductions in public long-term care spending led to substantial increases in the number of emergency department (ED) visits made by patients aged 65 and above, explaining between a quarter and a half of the growth in ED use among this population over this period, and to an increase in the share of patients revisiting the ED within seven days. However, there was no impact on wider use of inpatient or outpatient services (which are more expensive to provide), and consequently little impact on overall hospital costs.

The coronavirus pandemic has had huge impacts on the National Health Service (NHS). Patients suffering from the illness have placed unprecedented demands on acute care, particularly on Intensive Care Units (ICUs). This has led to an effort to dramatically increase the resources available to NHS hospitals in treating these patients, involving re‐organisation of hospital facilities, redeployment of existing staff and a drive to bring in recently retired and newly graduated staff to fight the pandemic. These increases in demand and changes to supply have had large knock‐on effects on the care provided to the wider population. This paper discusses likely implications for healthcare delivery in the short and medium term of the responses to the coronavirus pandemic, focusing primarily on the implications for non‐coronavirus patients. Patterns of past care suggest those most likely to be affected by these disruptions will be older individuals and those living in more deprived areas, potentially exacerbating pre‐existing health inequalities. Effects are likely to persist into the longer‐run, with particular challenges around recruitment and ongoing staff shortages. This article is protected by copyright. All rights reserved

This paper examines the impact of changes in public long-term care spending on the use of public hospitals among the older population in England. Mean per-person long-term care spending fell by 31% between 2009/10 and 2017/18, but cuts varied considerably geographically. We instrument public long-term care spending with predicted spending based on historical national funding shares and national spending trends. We find that reductions in public long-term care spending led to substantial increases in the number of emergency department (ED) visits made by patients aged 65 and above, explaining between a quarter and a half of the growth in ED use among this population over this period, and to an increase in the share of patients revisiting the ED within seven days. However, there was no impact on wider use of inpatient or outpatient services (which are more expensive to provide), and consequently little impact on overall hospital costs.

Funding the National Health Service is the biggest single thing the government does, so it is not surprising that it is at the forefront of the election campaign. In this report, we look at how health spending has changed over the last 70 years and place funding increases since 2010 in the context of the pressures associated with an ageing population. We then compare existing spending plans for the NHS to those implied by the political parties' manifestos at the 2017 general election and examine capital spending on the health service. Finally, we consider the longer term outlook for health spending.

Recent years have seen substantial reductions in public spending on social care for older people in England. This has not only led to large falls in the number of people over the age of 65 receiving publicly funded social care, but also to growing concern about the potential knock-on effects on other public services, and in particular the National Health Service (NHS). In this paper, we exploit regional variation in the reductions in public funding for social care to examine the impact on Accident and Emergency (A&E) departments in NHS hospitals. We find that reductions in social care spending on people aged 65 and above have led to increased use of A&E services, both in terms of the average number of visits per resident and the number of unique patients visiting A&E each year. We estimate that the average cut to social care spending for the older population over the period (£375) led to an increase of 0.09 visits per resident, compared to a mean of 0.37 visits in 2009. The effects are most pronounced among people aged 85 and above. This has also led to a modest increase in the cost of providing A&E care, increasing A&E costs by an additional £3 per resident for each £100 cut in social care funding.

On 5 July this year the NHS will be 70. In all its 70 years it has rarely been far from the headlines. It has been through more than its fair share of reforms, crises and funding ups and downs. Over that period, the amount we spend on it has risen inexorably. Yet, today, concerns about the adequacy of funding are once again hitting the headlines, as the health and social care systems struggle to cope with growing demand. Looking forward, funding pressures are only going to grow. The population is getting bigger and older, and expectations are rising along with the costs of meeting them. Our analysis suggests that UK spending on healthcare will have to rise by an average 3.3% a year over the next 15 years just to maintain NHS provision at current levels, and by at least 4% a year if services are to be improved. Social care funding will need to increase by 3.9% a year to meet the needs of an ageing population and an increasing number of younger adults living with disabilities. If the widely acknowledged problems with England's social care system - of limited eligibility, low quality and the perceived unfairness of the current, uncapped, means test - did result in reform, spending on social care would need to increase at a faster rate. [...]

The last 25 years have seen two periods of public expenditure restraint in the UK (the 1990s and the 2010s) and one period of increased spending (between 2000 and 2010). Over that whole time, the Treasury has been responsible for controlling government spending, setting fiscal rules and the overall control framework, and ensuring that other departments stay within their spending limits. In this report, we use data on spending plans and out-turns to see what they can tell us about the efficacy of spending control under different regimes. As well as different fiscal environments, and consequently different overall fiscal rules, over the periods there have also been different measures and targets for spending. During the 1990s, the then Conservative government was aiming to reduce public spending as a fraction of national income, and was targeting for control a measure of public spending dubbed the 'new control total'. This covered around 85% of public spending, including local authority spending and 'non-cyclical' social security spending, on pensions for example. It excluded the more cyclical elements of social security and debt interest payments. [...]