![]() ![]() The review offers insights on the drivers of the efficiency of national and sub-national health systems, and highlights potential targets for reforms to improve health system efficiency. It also reveals the dearth of efficiency studies that use mixed methods approaches by incorporating qualitative inquiry. This review highlights the limited evidence on health system efficiency, especially in low- and middle-income countries. Factors that were found to affect health system efficiency include demographic and socio-economic characteristics of the population, macro-economic characteristics of the national and sub-national regions, population health and wellbeing, the governance and political characteristics of these regions, and health system characteristics. Outputs used in efficiency analysis could be classified as either intermediate health service outputs (e.g., number of health facility visits), single health outcomes (e.g., infant mortality rate) or composite indices of either intermediate outputs of health outcomes (e.g., Health Adjusted Life Expectancy). While studies used a range of inputs, these generally considered the building blocks of health systems, health risk factors, and social determinants of health. A range of regression methods were used to identify the determinants of health system efficiency. Data envelopment analysis, a non-parametric method, was the most common methodological approach used, followed by stochastic frontier analysis, a parametric method. Only 6% of studies used either qualitative methods or mixed methods while 94% used quantitative approaches. There were also more publications focusing on national level (60%) compared to sub-national health systems’ efficiency. ![]() There were more publications from high- and upper middle-income countries (53%) than from low-income and lower middle-income countries. We analysed and synthesised evidence from the selected papers using a thematic approach (selecting, sorting, coding and charting collected data according to identified key issues and themes). We conducted a systematic search of PubMed and Google scholar between 20 and a manual search of relevant papers selected from their reference lists. We carried out a thematic review of literature that assessed the efficiency of health systems at the national and sub-national level. Efficiency analysis in the health sector has typically focused on the efficiency of healthcare facilities (hospitals, primary healthcare facilities), with few studies focusing on system level (national or sub-national) efficiency. Health system efficiency is a priority concern for policy makers globally as countries aim to achieve universal health coverage, and face the additional challenge of an aging population. Work continues on the other parts of this project.Efficiency refers the use of resources in ways that optimise desired outcomes. The winter 2017 cancellation may have been just one symptom of this overall pressure on planned surgery that underlies some of the longer-term changes in provision. There was a general decrease in planned operation capacity, mostly driven by increasing non-elective admissions even before the COVID-19 pandemic. This suggests an NHS-funded outsourcing of younger and less complex hip and knee replacement surgery to independent private providers. The proportion of more deprived people having knee replacements decreased, and the ratio of public to private provision of hip and knee replacements dropped after winter 2017. More hip and knee surgery patients had multiple long-term conditions following the pause. The average age for knee replacement increased after winter 2017. This was also reflected in a drop in bed occupancy for knee surgery. There was an immediate and sustained reduction in the number of knee replacements being done at the Trust following the pause. The pause does appear to have had some impact on these surgeries. We also looked at patient characteristics such as age, gender and social class.Ī total of 2,623 patients had a hip replacement and 2,674 had a knee replacement at the Trust in the four-year period. This created a ‘natural experiment’ where we could look at trends for these surgeries before and after the pause at a major NHS Trust, between 20. In the winter of 2017, the NHS paused planned hip and knee surgery for two months because of winter pressures. ![]() What we found and what this means The impact of pausing planned hip and knee surgery during winter pressures
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