Carol Propper

Imperial College London | Imperial · Imperial College Business School

Objective To examine the impact of nursing team size and composition on inpatient hospital mortality. Design A 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 a...

In the large literature on the spatial-level correlates of COVID-19, the association between quality of hospital care and outcomes has received little attention to date. To examine whether county-level mortality is correlated with measures of hospital performance, we assess daily cumulative deaths and pre-crisis measures of hospital quality, accoun...

Introduction Hospital admissions in many countries fell dramatically at the onset of the COVID-19 pandemic. Less is known about how care patterns differed by patient groups. We sought to determine whether areas with higher levels of socioeconomic deprivation or larger ethnic minority populations saw larger falls in emergency and planned admissions...

We examine variation in hospital quality across ownership, market concentration and membership of a hospital system. We use a measure of quality derived from the penalties imposed on hospitals under the flagship Hospital Readmissions Reduction Program. We employ a novel estimation approach that extracts latent hospital quality from panel data on pe...

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‐org...

We examine whether family doctor firms in England respond to local competition by increasing their quality. We measure quality in terms of clinical performance and patient-reported satisfaction to capture its multi-dimensional nature. We use a panel covering 8 years for over 8000 English general practices. We measure competition as the number of ri...

We study the causal impact of education on chronic health conditions by exploitng two UK education policy reforms. The first reform raised the minimum school leaving age in 1972 and affected the lower end of the educational attainment distribution. The second reform is a combination of several policy changes that affected the broader educational at...

Medical labour markets are important because of their size and the importance of medical labour in the production of healthcare and in subsequent patient outcomes. We present a summary of important trends in the UK medical labour market, and we review the latest research on factors that determine medical labour supply and the impact of labour on pa...

The use of competition and the associated increase in choice in health care is a popular reform model, adopted by many governments across the world. Yet it is also a hotly contested model, with opponents seeing it, at best, as a diversion of energy or a luxury and, at worst, as leading to health care inequality and waste. This paper subjects the us...

Data S1.

Choice in public services is controversial. We exploit a reform in the English National Health Service to assess the effect of remov- ing constraints on patient choice. We estimate a demand model that explicitly captures the removal of the choice constraints imposed on patients. We find that, post-removal, patients became more respon- sive to clini...

This paper reviews what is known about socioeconomic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair (‘inequities’). We call inequalities of 5% or less between most and least deprived socioeconomic quintile groups ‘slight’; inequalities of 6-15% ‘moderate’, and inequal...

The use of genetic markers as instrumental variables (IV) is receiving increasing attention from epidemiologists, economists, statisticians and social scientists. This paper examines the conditions that need to be met for genetic variants to be used as instruments. Although these have been discussed in the epidemiological, medical and statistical l...

The impact of teacher pay on school productivity is a central concern for governments worldwide, yet evidence is mixed. In this paper we exploit a feature of teacher labour markets to determine the impact of teacher wages. Teacher wages are commonly set in a manner that results in flat wages across heterogeneous labour markets. This creates an exog...

We investigate an underexplored externality of crime: the impact of violent crime on individuals’ participation in walking. For many adults walking is the only regular physical activity. We use a sample of nearly 1 million people in 323 small areas in England between 2005 and 2011 matched to quarterly crime data at the small area level. Within area...

The impacts of choice in public services are controversial. We exploit a reform in the English National Health Service to assess the impact of relaxing constraints on patient choice. We estimate a demand model that explicitly captures the referral constraints imposed on patients to evaluate whether removing constraints on choice increased the deman...

Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial pre-requisite in the English healthcare market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control ac...

To investigate the impact of increasing levels of inattention, hyperactivity/impulsivity, and oppositional/defiant behaviors at age 7 years on academic achievement at age 16 years. In a population-based sample of 7-year-old children in England, information was obtained about inattention, hyperactivity/impulsivity, and oppositional/defiant behaviors...

Understanding the socioeconomic gradient in physical inactivity is essential for effective health promotion. This paper exploits data on over one million individuals (1,002,216 people aged 16 and over) in England drawn from the Active People Survey (2004–11). We identify the separate associations between a variety of measures of physical inactivity...

Objectives To assess the association between market concentration of hospitals (as a proxy for competition) and patient-reported health gains after elective primary hip replacement surgery. Methods Patient Reported Outcome Measures data linked to NHS Hospital Episode Statistics in England in 2011/12 were used to analyse the association between mar...

We examine the effect of survey measurement error on the empirical relationship between child mental health and personal and family characteristics, and between child mental health and educational progress. Our contribution is to use unique UK survey data that contains (potentially biased) assessments of each child's mental state from three observe...

We undertake a detailed statistical investigation of the sensitivity of estimates of the prevalence of childhood mental health problems to the provider of the health assessment, with particular focus on the implications for the estimates of the income gradient in childhood mental health. We directly compare evaluations from children, their parents...

The effect of competition on the quality of health care remains a contested issue. Most empirical estimates rely on inference from nonexperimental data. In contrast, this paper exploits a procompetitive policy reform to provide estimates of the impact of competition on hospital outcomes. The English government introduced a policy in 2006 to promote...

Using a tried and tested measure of management practices which has been shown to predict firm performance, we survey nearly 250 departments across 100+ UK universities. We find large differences in management scores across universities and that departments in older, research-intensive universities score higher than departments in newer, more teachi...

High levels of attentional and hyperactivity problems in school-aged children, even if subthreshold for attention-deficit hyperactivity disorder (ADHD), are associated with academic under-achievement. Few large-scale, community-based studies have investigated the relationship between pre-school and adolescence. To investigate whether pre-school hyp...

This paper examines the record of the 1997–2010 Labour administration on health and healthcare. It begins by outlining the policies adopted by the administration with respect to the delivery of healthcare services and population health. It then presents a two-part assessment. In the first part we examine the performance of the administration with r...

Height has long been recognised as associated with better outcomes: the question is whether this association is causal. We use children’s genetic variants as instrumental variables (IV) to deal with possible unobserved confounders and examine the effect of child and adolescent height on a wide range of outcomes: academic performance, IQ, self-estee...

Background Socioeconomic inequalities are a key policy challenge. Studies to date have not taken a unified approach to assess how socioeconomic inequalities in health, behaviour and educational attainment change as children age. Methods We examined maternal education inequalities in multiple offspring health, behavioural and educational outcomes a...

The impacts of choice in public services are controversial. We exploit a reform in the English National Health Service to assess the impact of relaxing constraints on patient choice. We estimate a demand model to evaluate whether increased choice increased demand elasticity faced by hospitals with regard to clinical quality and waiting time for an...

The literature that examines the relationship between child or adolescent Body Mass Index (BMI) and academic attainment generally finds mixed results. This may be due to the use of different data sets, conditioning variables, or methodologies: studies either use an individual fixed effects (FE) approach and/or an instrumental variable (IV) specific...

The literature on mergers between private hospitals suggests that such mergers often produce little benefit. Despite this, the UK government has pursued an active policy of hospital mergers, arguing that such consolidations will bring improvements for patients. We examine whether this promise is met. We exploit the fact that between 1997 and 2006 i...

UK governments of all political colours have sought to improve productivity in health care by introducing pro-competitive reforms in the National Health Service (NHS) during the last two decades. The first wave of reform operated from 1991 to 1997. The second wave was introduced in England only in the mid 2000s. In 2010, further reform in England,...

This article scrutinizes the empirical literature on competition between providers and finds that the outcomes are highly varied, and that competition generates winners and losers among patients as well as providers. It examines the theoretical and empirical economic evidence on the effect of greater competition between providers in health care mar...

The medical workforce is important based merely on its size and takes on even greater importance given the influence physicians, nurses, dentists, and pharmacists have on patient treatment. On the supply side, most governments regulate health professions to assure that the inputs into the health production function are of sufficiently high quality....

In their Comment (published online Oct 10), Allyson Pollock and colleagues misrepresent our research. Although such work might run counter to Pollock and colleagues' prior beliefs, this is not grounds to dismiss it. Nowhere in their review have Pollock and colleagues given evidence that the reforms we studied have harmed patients' outcomes. Instead...

In response to May’s concern that competition achieves relatively small gains,1 we have attempted some “back of the envelope” valuations of the gains from the choice and competition policy. Our research suggests that an average hospital’s all cause standardised mortality rate fell by 0.3% …

Recent studies have demonstrated the importance of good management for firm performance. Here, we focus on management in not-for-profits (NFPs). We present a model predicting that management quality will be lower in NFPs compared to for-profits (FPs), but that outputs may not be worse if managers are altruistic. Using a tried and tested survey of m...

There is relatively little research on peer effects in teenage motherhood despite the fact that peer effects, and in particular social interaction within the family, are likely to be important. We estimate the impact of an elder sister’s teenage fertility on the teenage childbearing of their younger sister. To identify the peer effect we utilize an...

We use an experiment to study the impact of team-based incentives, exploiting rich data from personnel records and management information systems. Using a triple difference design, we show that the incentive scheme had an impact on team performance, even with quite large teams. We examine whether this effect was due to increased effort from workers...

Economists have long warned of the unintended consequences of labour market regulation (Botero et al. 2004). Some things that seem fair - like paying people the same wage for doing the same job regardless of where they work - may turn out to be foul in practice. Although people often worry about the minimum wage pricing people out of jobs, a regula...

The use of genetic markers as instrumental variables (IV) is receiving increasing attention from economists. This paper examines the conditions that need to be met for genetic variants to be used as instruments. We combine the IV literature with that from genetic epidemiology, with an application to child adiposity (fat mass) and academic performan...

We analyse the causal impact of competition on managerial quality and hospital performance. To address the endogeneity of market structure we analyse the English public hospital sector where entry and exit are controlled by the central government. Because closing hospitals in areas where the governing party is expecting a tight election race (“marg...

In many sectors, pay is regulated to be equal across heterogeneous geographical labor markets. When the competitive outside wage is higher than the regulated wage, there are likely to be falls in quality. We exploit panel data from the population of English hospitals in which regulated pay for nurses is essentially flat across the country. Higher o...

A large literature uses parental evaluations of child health status to provide evidence on the socioeconomic determinants of health. If how parents perceive health questions differs by income or education level, then estimates of the socioeconomic gradient are likely to be biased and potentially misleading. In this paper we examine this issue. We d...

The current air quality limit values for airborne pollutants in the UK are low by historical standards and are at levels that are believed not to harm health. We assess whether this view is correct. We examine the relationship between common sources of airborne pollution and population mortality for England. We use data at local authority level for...

Economists rely heavily on self-reported measures of health to examine the relationship between income and health. We directly compare survey responses of a self-reported measure of health that is commonly used in nationally representative surveys with objective measures of the same health condition. We focus on hypertension. We find no evidence of...

This paper evaluates the impact of a performance-related pay scheme for teachers in England. Using data which matches individual pupils to individual teachers, and contains both test scores and value-added, we test whether the introduction of a payment scheme based on pupil attainment increased teacher effort. Our evaluation design controls for pup...

Letter: We were interested to read the article by Knox (Knox G., Atmospheric pollutants and mortalities in English local authority areas. J Epidemiol Community Health 2008, 62: 442-7) on the new approach to using local authority data in addressing the effects of air pollution on health. To our knowledge, this has been done only once before and do...

Performance targets are commonly used in the public sector, despite their well known problems when organisations have multiple objectives and performance is difficult to measure. It is possible that such targets may work where there is considerable consensus that performance needs to be improved. We investigate this possibility by examining the res...

This paper examines the transitions from primary to secondary school for a contemporary cohort of children moving between state schools in England. It uses data on over 12 000 primary schools, over 2000 secondary schools and around 400 000 pupils. The results suggest that the experiences of poor pupils at age 11 may be quite different, on average,...

We test empirically whether people’s life satisfaction depends on their relative income position in the neighbourhood, drawing on a unique dataset, the German Socio-economic Panel Study (SOEP) matched with micro-marketing indicators of population characteristics. Relative deprivation theory suggests that individuals are happier the better their rel...

Labour market regulation can have harmful unintended consequences. In many markets, especially for public sector workers, pay is regulated to be the same for individuals across heterogeneous geographical labour markets. We would predict that this will mean labour supply problems and potential falls in the quality of service provision in areas with...

This paper uses a cohort of 12,000 births to examine the effect of maternity rights on mothers' post-birth return to employment decisions. It uses a discrete hazard model to disentangle the effects of the terms of maternity rights entitlements from other factors that influence the timing of a mother's return to work. Mothers with rights have an und...

Recent reforms to the provision of welfare services by the public sector have transferred control rights in production from politicians to managers and simultaneously introduced competition between public sector suppliers. We derive conditions under which a self-interested politician will introduce either competition and/or managerial control for s...

Labor market regulation can have harmful unintended consequences. In many markets, especially for public sector workers, pay is regulated to be the same for individuals across heterogeneous geographical labor markets. We would predict that this will mean labor supply problems and potential falls in the quality of service provision in areas with str...

Declining fertility is often attributed to the increased education of women. It is difficult to establish a causal link because both fertility and education have changed secularly. In this paper we study the connection between fertility and education using educational reform as an instrument to control for selection. Our results indicate that incre...

In this paper we explore the association between family income and children’s cognitive ability (IQ and school performance), socio-emotional outcomes (self esteem, locus of control and behavioural problems) and physical health (risk of obesity). We develop a decomposition technique that allows us to compare the relative importance of the adverse fa...

This article exploits policy change by the UK government to identify the impact of competition on quality. It uses differences in competition over time and space to examine the impact of competition in an environment with limited quality signals in which hospitals competed mainly on price. Using AMI mortality as a measure of hospital quality we fin...

Waiting times have been a central concern in the English NHS, where care is provided free at the point of delivery and is rationed by waiting time. Pro-market reforms introduced in the NHS in the 1990s were not accompanied by large drops in waiting times. As a result, the English government in 2000 adopted the use of an aggressive policy of targets...

The effect of a more able peer group on a child’s attainment is considered an integral part in estimating a pupil level educational production function. Examinations in England at age 16 are tiered according to ability, leading to a large stratification of pupils by ability. However, within tiers, there is a range of policies between schools regard...