Publications
149 results found
Halonen-Akatwijuka M, Propper C, 2024, Competition, equity and quality in public services
This paper examines the implications of consumer heterogeneity for the choice of competition and monopoly in public services delivery. In a setting with motivated providers who favour one type of service user over another, we show that competition can raise average quality. However, this may be at the expense of the minority type of user if the providers favour the majority type. Then an inequity averse regulator may protect the minority by not introducing competition. Alternatively, if the providers favour the minority type, the regulator may introduce competition to incentivize the providers to pay attention to the less rewarding majority type.
Propper C, 2024, Competition, Equity and Quality in Public Services, European Economic Review, ISSN: 0014-2921
Avdic D, von Hinke S, Lagerqvist B, et al., 2024, Do responses to news matter? Evidence from interventional cardiology, Journal of Health Economics, Vol: 94, ISSN: 0167-6296
We examine physician responses to a global information shock and how these impact their patients. We exploit international news over the safety of an innovation in healthcare, the drug-eluting stent. We use data on interventional cardiologists’ use of stents to define and measure cardiologists’ responsiveness to the initial positive news and link this to their patients’ outcomes. We find substantial heterogeneity in responsiveness to news. Patients treated by cardiologists who respond slowly to the initial positive news have fewer adverse outcomes. This is not due to patient–physician sorting. Instead, our results suggest that the differences are partially driven by slow responders being better at deciding when (not) to use the new technology, which in turn affects their patient outcomes.
Propper C, 2023, Socio-economic inequality in the distribution of health care in the UK, Oxford Open Economics, ISSN: 2752-5074
Janke K, Lee K, Propper C, et al., 2023, Economic conditions and health: local effects, national effect and local area heterogeneity, Journal of Economic Behavior and Organization, Vol: 214, Pages: 801-828, ISSN: 0167-2681
We study the relationship between health and changing economic conditions in local areas using a GVAR model that allows for dynamic and interdependent responses to local and national economic conditions. We examine quarterly British data for 2002–2016 for 131 local areas, which displays considerable heterogeneity in economic conditions. We find robust evidence that health improves as the local economy (employment) expands, but that it takes over 2 years to realise the full effect. This relationship holds for musculoskeletal, cardiovascular, respiratory, and mental health conditions. We find considerable response heterogeneity at the local area level with the strongest relationship between changes in economic conditions and health found for areas with more traditional industrial structures.
Zaranko B, Sanford NJ, Kelly E, et al., 2023, Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study, BMJ Quality & Safety, Vol: 32, Pages: 254-263, ISSN: 2044-5423
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 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.Setting Three hospitals within a single National Health Service Trust in England.Participants 19 287 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 measure In-hospital deaths.Results A 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).Conclusions RN 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.
Kunz J, Propper C, 2023, JUE Insight: Is hospital quality predictive of pandemic deaths? evidence from US counties, Journal of Urban Economics, Vol: 133, ISSN: 0094-1190
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, accounting for state �xed-e�ects and potential confounders. As a measure of quality, we use the pre-pandemic adjusted �ve-year penalty rates for excess 30-day readmissions following pneumonia admissions for the hospitals accessible to county residents based on ambulance travel patterns. Our adjustment corrects for socio-economic status and down-weighs observations based on small samples. We �nd that a one-standard-deviation increase in the quality of local hospitals is associated with a 2% lower death rate (relative to the mean of 20 deaths per 10,000 people) one and a half years after the �rst recorded death.
Kunz J, Propper C, Staub KE, et al., 2022, Assessing the Quality of Public Services: For-Profits, Chains, and Concentration in the Hospital Market
Dzhygyr Y, Maynzynk K, Murphy A, et al., 2022, The health system, Rebuilding Ukraine: Principles and Policies, Editors: Gorodnickcenko, Sologub, Pages: 361-384
Russia’s full-scale invasion has had a devastating impact on Ukraine’s health system.Our overall recommendation is that international aid and resources devoted to Ukraine’srecovery should be used to help the system to ‘leapfrog’ – to modernise the healthcaresystem so that it can deliver care more efficiently to meet the goal of universal accessto affordable and high-quality care. To this end, we offer a set of key recommendations.These are presented according to the corresponding WHO Health System Building Blockframework.In terms of financing, we recommend that international aid be channelled through asingle independent agency and aligned with Ukraine’s objectives, and that formal costsharing should be avoided as it may exacerbate the existing problem of informal out ofpocket payments and is unlikely to generate significant revenue. For healthcare delivery,we suggest (1) explicitly defining the basic healthcare benefit package (the Programme ofMedical Guarantees, or PMG) now, to avoid implicit rationing through refusal of care oruse of informal out-of-pocket payments, and to improve efficiency; and (2) introducing amix of public and private provision in the short and longer term, with one central agencyresponsible for contracts.Managing healthcare workforce should focus on (1) careful use of task-sharing to nurses,initially in primary care, supported by training and supervision; and (2) increased effortsto retrain staff in line with European standards and the changing health needs of thepopulation. This should be complemented with investments in staff retention, by meansof better working practices and higher salaries. There should be strong investment inhealth information systems to address issues of security and interoperability betweendifferent healthcare providers. Governance and leadership should aim to achieve two objectives: (1) developing thecurrent purchasing agency, the National Health Service of Ukraine (NHSU), int
Warner M, Burn S, Stoye G, et al., 2022, Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: a national observational study, BMJ Quality & Safety, Vol: 31, Pages: 590-598, ISSN: 2044-5415
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 in England.Methods We conducted a national observational study of hospital care in the English National Health Service (NHS) in 2019–2020. Weekly volumes of elective (planned) and emergency admissions in 2020 compared with 2019 were calculated for each census area. Multiple linear regression analysis was used to estimate the reductions in volumes for areas in different quintiles of socioeconomic deprivation and ethnic minority populations after controlling for national time trends and local area composition.Results Between March and December 2020, there were 35.5% (3.0 million) fewer elective admissions and 22.0% (1.2 million) fewer emergency admissions with a non-COVID-19 primary diagnosis than in 2019. Areas with the largest share of ethnic minority populations experienced a 36.7% (95% CI 24.1% to 49.3%) larger reduction in non-primary COVID-19 emergency admissions compared with those with the smallest. The most deprived areas experienced a 10.1% (95% CI 2.6% to 17.7%) smaller reduction in non-COVID-19 emergency admissions compared with the least deprived. These patterns are not explained by differential prevalence of COVID-19 cases by area.Conclusions Even in a healthcare system founded on the principle of equal access for equal need, the impact of COVID-19 on NHS hospital care for non-COVID patients has not been spread evenly by ethnicity and deprivation in England. While we cannot conclusively determine the mechanisms behind these differences, they risk exacerbating prepandemic health inequalities.Data availability statementData may be obtained from a third party and are not publicly available.
Propper C, Gruber J, Lordan G, et al., 2022, The impact of mental health support for the chronically ill on hospital utilisation: Evidence from the UK, Social Science and Medicine, Vol: 294, ISSN: 0277-9536
Individuals with common mental disorders (CMDs) such as depression and anxiety frequently have co-occurring long-term physical health conditions (LTCs) and this co-occurrence is associated with higher hospital utilisation. Psychological treatment for CMDs may reduce healthcare utilisation through better management of the LTC, but there is little previous research. We examined the impact of psychological treatment delivered under the nationwide Improving Access to Psychological Therapies (IAPT) programme in England on hospital utilisation 12-months after the end of IAPT treatment. We examined three types of hospital utilisation: Inpatient treatment, Outpatient treatment and Emergency room attendance. We examined individuals with Chronic Obstructive Pulmonary Disease (COPD) (n=816), Diabetes (n=2813) or Cardiovascular Disease (CVD) (n=4115) who received psychological treatment between April 2014 and March 2016. IAPT episode data was linked to hospital utilisation data which went up March 2017. Changes in the probability of hospital utilisation were compared to a matched control sample for each LTC. Individuals in the control sample received IAPT treatment between April 2017 and March 2018. Compared to the control sample, the treated sample had significant reductions in the probability of all three types of hospital utilisation, for all three LTCs 12-months after the end of IAPT treatment. Reductions in utilisation of Emergency Room, Outpatient and non-elective Inpatient treatment were also observed immediately following the end of psychological treatment, and 6-months after, for individuals with diabetes and CVD, compared to the matched sample. These findings suggest that psychological interventions for CMDs delivered to individuals with co-occurring long-term chronic conditions may reduce the probability of utilisation of hospital services. Our results support the roll-out of psychological treatment aimed at individuals who have co-occurring common mental disorders a
Barrenho E, Miraldo M, Propper C, et al., 2021, The importance of surgeons and their peers in adoption and diffusion of innovation: an observational study of laparoscopic colectomy adoption and diffusion in England, Social Science and Medicine, Vol: 272, ISSN: 0277-9536
Little is known about the role of clinicians in accounting for adoption and diffusion of medical innovations, especially within the English National Health System. This study examines the importance of surgical consultants and their work-based networks on the diffusion of an important innovation, minimally invasive elective laparoscopic colectomy for colorectal cancer. The study used linked patient-level and workforce data on 260,110 elective colectomies and 1288 consultants between 2000 and 2014, to examine adoption of laparoscopic colectomy pre- and post-introduction of clinical guidelines and total share of colectomies performed laparoscopically by adopters. Laparoscopy as a share of elective colectomy increased from 0% in 2000 to 53% in 2014. Surgeons, rather than hospitals, were the principal agents accounting for the increase and explain 46.6% of the variance in laparoscopic colectomy use. Female surgeons, surgeons trained outside the United Kingdom, and recent graduates had higher rates of laparoscopy adoption. More experienced surgeons and surgeons with more peers who perform laparoscopy were more likely to adopt, adopt early and have greater use of laparoscopy. Targeting clinicians, rather than hospitals, is central to increasing adoption and diffusion of new medical technologies.
Barrenho E, Gautier E, Miraldo M, et al., 2020, Innovation Diffusion and Physician Networks: Keyhole Surgery for Cancer in the English NHS
Propper C, Stoye G, Zaranko B, 2020, The wider impacts of the coronavirus pandemic on the NHS*, Fiscal Studies, Vol: 41, Pages: 345-356, ISSN: 0143-5671
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 reorganisation 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.
Banks J, Karjalainen H, Propper C, 2020, Recessions and health: the long‐term health consequences of responses to the coronavirus, Fiscal Studies, Vol: 41, Pages: 337-344, ISSN: 0143-5671
The lockdown measures that were implemented in the spring of 2020 to stop the spread of COVID‐19 are having a huge impact on economies in the UK and around the world. In addition to the direct impact of COVID‐19 on health, the following recession will have an impact on people's health outcomes. This paper reviews economic literature on the longer‐run health impacts of business‐cycle fluctuations and recessions. Previous studies show that an economic downturn, which affects people through increased unemployment, lower incomes and increased uncertainty, will have significant consequences on people's health outcomes both in the short and longer term. The health effects caused by these adverse macroeconomic conditions will be complex and will differ across generations, regions and socio‐economic groups. Groups that are vulnerable to poor health are likely to be hit hardest even if the crisis hit all individuals equally, and we already see that some groups such as young workers and women are worse hit by the recession than others. Government policies during and after the pandemic will play an important role in determining the eventual health consequences.
Kunz J, Propper C, 2020, "Does Higher Hospital Quality Save Lives? the Association between" "COVID-19 Deaths and Hospital Quality in the USA
Kunz J, Propper C, Staub KE, et al., 2020, Assessing the Quality of Public Services: Does Hospital Competition Crowd Out the For-Profit Quality Gap?
Propper C, Shields M, Janke K, et al., 2020, The causal effect of education on chronic health conditions in the UK, Journal of Health Economics, Vol: 70, ISSN: 0167-6296
We study the causal impact of education on chronic health conditions by exploitng two UK educationpolicy reforms. The first reform raised the minimum school leaving age in 1972 and affected the lowerend of the educational attainment distribution. The second reform is a combination of several policychanges that affected the broader educational attainment distribution in the early 1990s. Results areconsistent across both reforms: an extra year of schooling has no statistically identifiable impact onthe prevalence of most chronic health conditions. The exception is that both reforms led to astatistically significant reduction in the probability of having diabetes, and this result is robust acrossmodel specifications. However, even with the largest survey samples available in the UK, we areunable to statistically rule out moderate size educational effects for many of the other health conditions,although we generally find considerably smaller effects than OLS associations suggest.
Janke K, Lee K, Propper C, et al., 2020, Macroeconomic Conditions and Health in Britain: Aggregation, Dynamics and Local Area Heterogeneity
Lee T, Propper C, Stoye G, 2020, Medical labour supply and the production of healthcare, Fiscal Studies, Vol: 40, Pages: 621-661, ISSN: 0143-5671
Medical labour markets are important due to their size and the importanceof medical labour in the production of healthcare and subsequent patient outcomes. We present a summary of important trends in the UK medical labourmarket, and review the latest research on factors that determine medical laboursupply and the impact of labour on patient outcomes. The topics examinedinclude the responsiveness of labour supply to changes in wages, regulationand other incentives; factors which determine the wide variation in physicianpractice and style; and the effect of teams and management quality on patientoutcomes. This literature reveals that while labour supply is relatively unresponsive to changes in wages, medical personnel do react strongly to otherincentives even in the short run. This is likely to have consequences for quality of care provided to patients. We set out a series of unanswered questionsin the UK setting, including: the importance of non-financial incentives inrecruiting and retaining medical staff; how individuals can be incentivised towork in particular specialties and regions; and how medical teams can be bestorganised to improve care.
Black N, Shields M, Propper C, et al., 2019, The effect of school sports facilities on physical activity, health and socioeconomic status in adulthood, Social Science and Medicine, Vol: 220, Pages: 120-128, ISSN: 0277-9536
This paper focuses on the long-term impacts of attending a high school with inadequate sports facilities. We use prospective data from the British National Child Development Study, a continuing panel of a cohort of 17,634 children born in Great Britain during a single week of March 1958. Our empirical approach exploits the educational system they were exposed to: children were sorted by educational ability at age 11, but conditional on educational ability, attended their closest school. This produces quasi-random variation in the quality of the school sports facilities across respondents. We use this variation between cohort members residing within the same local authority area, and focus on outcome measures of physical activity, health, health-related lifestyle activities, and socioeconomic status, collected at ages between 33 and 50 years. We control for any potential links between the inadequacy of sports facilities and inadequacy of other facility types, and test that allocation to school type is random with respect to pre-high school observables. We find that attending a school with inadequate sports facilities led to a statistically significant, modest decrease in the likelihood of physical activity participation during adulthood. In contrast, we find no evidence that inadequate sports facilities worsened adulthood measures of physical and mental health, lifestyle or socioeconomic status.
Miraldo M, Propper C, Williams R, 2018, The impact of publicly subsidised health insurance on access, behavioural risk factors and disease management, Social Science and Medicine, Vol: 217, Pages: 135-151, ISSN: 0277-9536
In 2006, the Massachusetts healthcare reform was introduced to mandate health insurance, extend eligibility of publicly subsidised health insurance, improve quality and access to care and develop preventive health services. The objective of this study was to determine the impact of expanding publicly subsidised health insurance through the Massachusetts reform on access to primary care, disease management and behavioural risk factors. Using cross-sectional data from the Behavioural Risk Factor Surveillance System (BRFSS) from 2001 to 2010 and exploiting the selective introduction of the healthcare reform, we assessed its impact on primary care access, behavioural risk factors, such as obesity, and receipt of diabetes management tests. We did so using a differences-in-differences methodology by comparing Massachusetts with other New England States for 131,002 adults under 300% of the federal poverty level and by race/ethnicity within this group. Triple difference estimates were also conducted to control for potential within state time varying confounding factors. The results suggest that increasing publicly subsidised health insurance had a positive impact on primary care access for lower income adults, particularly those that are white. However, with the exception of improvements in alcohol consumption for one specific group (lower income whites) the reform had no effect on behaviour risk factors or diabetes disease management. The aims of the reform were to improve access to care and through this, behavioural risk factors and diabetes management. This study suggests that while access to care was increased, reducing risk factors attributed to health risky behaviour and diabetes cannot be sufficiently done simply by extending health insurance coverage and the provision of preventive services. This suggests that more targeted interventions are required.
Propper C, 2018, Competition in health care: Lessons from the English experience, Health Economics, Policy and Law, Vol: 13, Pages: 492-508, ISSN: 1744-1331
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 use of competition in health care to scrutiny. It begins by examining the theoretical case and then argues that only by looking at evidence can we understand what works and when. The body of the paper examines the evidence for England. For 25 years the United Kingdom has been subject to a series of policy changes which exogenously introduced and then downplayed the use of competition in health care. This makes England a very useful test bed. The paper presents the UK reforms and then discusses the evidence of their impact, examining changes in outcomes, including quality, productivity and the effect on the distribution of health care resources across socio-economic groups. The final section reflects on what can be learnt from these findings.
Burgess S, Propper C, Tominey E, 2017, Incentives in the public sector: evidence from a governmentagency, Economic Journal, Vol: 127, Pages: F117-F141, ISSN: 1468-0297
We study the impact of team-based performance pay in a major UK government agency, thepublic employment service. The scheme covered quantity and quality targets, measured withvarying degrees of precision. We use unique data from the agency’s performancemanagement system and personnel records, linked to local labour market data. We show thaton average the scheme had no significant effect but had a substantial positive effect in smallteams, fitting an explanation combining free riding and peer monitoring. We also show thatthe impact was greater on better-measured quantity outcomes than quality outcomes. Thescheme was very cost effective in small offices.
Jones D, Propper C, Smith S, 2017, Wolves in sheep’s clothing: Is non-profit status used to signal quality?, Journal of Health Economics, Vol: 55, Pages: 108-120, ISSN: 0167-6296
Why do many firms in the healthcare sector adopt non-profit status? One argument is that non-profit status serves as a signal of quality when consumers are not well informed. A testable implication is that an increase in consumer information may lead to a reduction in the number of non-profits in a market. We test this idea empirically by exploiting an exogenous increase in consumer information in the US nursing home industry. We find that the information shock led to a reduction in the share of non-profit homes, driven by a combination of home closure and sector switching. The lowest quality non-profits were the most likely to exit. Our results have important implications for the effects of reforms to increase consumer provision in a number of public services.
Jones DB, Propper C, Smith S, 2017, Wolves in sheep's clothing: Is non-profit status used to signal quality?, JOURNAL OF HEALTH ECONOMICS, Vol: 55, Pages: 108-120, ISSN: 0167-6296
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Santos R, Gravelle H, Propper C, 2017, Does quality affect patients’ choice of Doctor? Evidence from England, The Economic Journal, Vol: 127, Pages: 445-494, ISSN: 1468-0297
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 prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%.
Cookson R, Propper C, Asaria M, et al., 2016, Socioeconomic inequalities in health care in England, Fiscal Studies, Vol: 37, Pages: 371-403, ISSN: 1475-5890
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 inequalities of > 15% “substantial”. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people’s experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (e.g. dental checkups, eye tests, screening and vaccination) and a few specific treatments (e.g. hip and knee replacement). Studies of population health care outcomes (e.g. avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health over the lifecourse, alongside many other socioeconomically patterned inputs including environmental factors (e.g. living and working conditions), consumption (e.g. diet, smoking), self care (e.g. seeking medical information) and informal care (e.g. support from family and friends).
Gaynor M, Propper C, Seiler S, 2016, Free to Choose? Reform, Choice, and Consideration Sets in the English National Health Service, American Economic Review, Vol: 106, Pages: 3521-3557, ISSN: 0002-8282
<jats:p> Choice in public services is controversial. We exploit a reform in the English National Health Service to assess the effect of removing 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 responsive to clinical quality. This led to a modest reduction in mortality and a substantial increase in patient welfare. The elasticity of demand faced by hospitals increased substantially post-reform and we find evidence that hospitals responded to the enhanced incentives by improving quality. This suggests greater choice can raise quality. (JEL D12, I11, I18) </jats:p>
Janke K, Propper C, Shields MA, 2016, Assaults, murders and walkers: The impact of violent crime on physical activity, Journal of Health Economics, Vol: 47, Pages: 34-49, ISSN: 0167-6296
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 variation identifies the causal effect of local violent crime on walking and a difference-in-difference analysis of two high-profile crimes corroborates our results. We find a significant deterrent effect of violent crime on walking that translates into a drop in overall physical activity.
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