Allocation of NHS resources: are some patients more equal than others?BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3362 (Published 15 May 2012) Cite this as: BMJ 2012;344:e3362
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Rapid response to Hawkes N. Allocation of NHS resources: are some patients more equal than others ? BMJ 2012;344:e3362 (15 May)
From John M. Hacking, Senior Research Officer, Public Health Manchester.
The assumption is made by Nigel Hawkes1 that a policy of directing resources towards areas of high deprivation has ‘largely failed’ to reduce health inequalities between these areas and areas of lower deprivation. I would challenge this on two grounds. Firstly there are many factors other than NHS allocations which affect health inequalities, for example changes in the economy, environment and migration. Because the effects of all these factors are difficult to disentangle and may be affecting health inequalities in different directions, it is not possible to substantiate a statement that ‘this policy has largely failed’ – it is always possible that without such a policy things would have got worse.
My second ground for challenge is more basic – it is not clear at all that deprived areas have in fact received significant amounts of extra allocation over and above those they get under the principle of ‘equal access for equal need’. Although the recent additional needs formula based on disability free life expectancy has been named the ‘health inequalities formula’ its derivation seems to be based mainly on estimates of ‘unmet need’ in deprived areas and therefore it falls under the ‘equal access’ principle. Thus the Advisory Committee on Resource Allocation (ACRA) saw the current health inequalities formula as one that is ‘responsive to currently unmet need and to the low quality of care delivered to disadvantaged groups’2. There were specific extra allocations given to deprived areas a decade ago under the banner of health inequalities but these were relatively very small. There were also extra allocations, ostensibly for public health, in 2006-8 to the one fifth of PCTs with poorest health, but these were also very small. Consequently the policy that has ‘largely failed’ has in fact never properly got off the ground with clearly defined and substantial amounts of resource. If and when the ring fenced public health allocations become more substantial in total and more highly skewed than at present to deprived areas, then such a policy may be said to have commenced. Alternatively or additionally the same could be said of any decision made by the NHS commissioning board to allocate significant extra funds to deprived CCGs over and above the ‘equal access’ principle.
The same article quotes a figure of 40% as additional NHS per capita funding of Central Manchester compared with North Devon, and uses this figure to suggest that the balance between deprivation and age weightings is too skewed towards deprivation. In fact this figure relates to obsolete formulae and old geography. The latest comparison is for 2011/12 where Manchester PCT receives only 17% more per head than Devon PCT. This begins to look rather a small difference when one compares the health statistics of the two areas. For 2006-10 data males in Manchester live 6.5 years less on average than those in Devon and females 5.7 years less. The disability free life expectancy difference for males and females combined (as used in the health inequalities formula) is even worse at 10.3 years.
Two other issues raised in the article invite comment. Firstly the article carries an implication that health inequalities are caused mainly by lifestyle choices of those with worse health. This was not borne out in my study with colleagues from the University of Manchester of the north south divide in mortality in England3. The two lifestyle choices which probably account for the largest effect on premature mortality viz Smoking and drinking only accounted for one sixth of the excess deaths in the north compared with the south.
Secondly there is mention of the possibility of a faster ‘pace of change’, the rate at which PCTs or CCGs move towards their formula target allocation, in the move from PCTs to CCGs. There has been a lot of sympathy in deprived PCTs for a faster pace of change because they have in the past, though not so much recently, been the main ‘losers’ from the typically glacial pace set by ministers. The main ‘winner’ has been London which is currently 6.6% or £867 million over target allocation, with six London PCTs being astonishingly highly over-target in the range 15 to 23 %. Whilst a faster pace of change in the future would seem fairer all round it is difficult to see how a change in organisation geography alone can bring this about when the baseline spend of each new organisations is determined by that of their progenitor.
1. Hawkes N. Allocation of NHS resources: are some patients more equal than others ? BMJ 2012;344:e3362 (15 May)
2. Dept of Health. Report of the Advisory Committee on Resource Allocation. Dec 2008.
3. Hacking JM, Muller S, Buchan IE. Trends in mortality from 1965 to
2008 across the English north-south divide: comparative observational
study. BMJ. 2011 Feb 15;342:d508. doi: 10.1136/bmj.d508
Competing interests: No competing interests
Professor Bambra misquotes Nigel Hawkes’ well informed and nuanced piece by suggesting that he has pointed out the dangerous implications for health inequalities of “an age only proposal” for NHS resource allocation.
Nobody has ever suggested that age alone should determine allocations. What Mr Lansley actually said was that those deciding allocations should be looking at the “respective burden of disease” and that age was the principal determinant of disease burden. He has also made it clear that funding for public health will be based on indices of deprivation with an expectation that money will be spent on tackling poverty-related health need.
Professor Bambra’s analysis of what would happen if allocations were based on age alone is thus based on an entirely false premise.
It is nevertheless the case that, with respect to the part of the formula the supports the objective of equal opportunity of access for equal needs, deprived areas will lose out if a greater weight is given to age than is currently the case. The question that we should be asking is whether this is unfair.
For most conditions (mental health excluded), age is a more significant determinant of morbidity and mortality than deprivation. Thus, the health communities grappling with the highest burdens of chronic illness and disability – in crude terms - serve the most ageing areas.
Currently, these areas do not receive the highest NHS allocations. The most deprived areas are the most generously funded. These areas have the highest mortality and morbidity rates – in standardised terms. However, because they also tend to have younger demographic profiles, they have relatively low crude burdens of disease and thus relatively low needs for curative NHS care.
The most deprived areas benefit from astonishingly high allocations relative to underlying morbidity. Take Tower Hamlets, which received a per capita NHS allocation of £2,084.35 in 2010-11. Only 3.4 per cent of this area’s population is over 75. Crude mortality Rate (CMR) is 441 per 100,000, Coronary Heart Disease (CHD) QOF registrations 1.78% and cancer registrations 0.77%. A similar profile is found in nearby Newham (3.5% 75+; CMR 540; CHD 1.78%; cancer 0.62%). Newham receives £2,116.47 of NHS funding per capita.
Dorset, by contrast, has the highest proportion of the population aged 75-plus (12.7%). Its CMR is 1,159 per 100,000; CHD rate 4.83% and cancer rate 2.49%. Its overall per capita NHS allocation is £1,560.50. Hastings and Rother similarly has to meet the health needs associated with an ageing population (12.1% 75+; CMR 1,276; CHD 4.16; cancer 2.01%) with a relatively low revenue base (£1,837 per capita).
Is this fair? It rather depends on whether one believes that the NHS still has a role in promoting equal access for equal needs. If one cares about health care equity, current differences in expenditure are very hard to justify. Take cancer expenditure per cancer patient. Tower Hamlets and Newham spend £13,087 and £11,080 respectively; Dorset and Hastings and Rother £4,075 and £6,282.
While the very high allocations given to Inner London PCTs do distort the national picture, these figures are symptomatic of a pattern in which young, deprived populations with lower crude rates of illness and death receive and spend significantly higher NHS allocations than their older, more affluent counterparts.
In the North West SHA, for example, Manchester (5.4% 75+; cancer 1.08%) receives a per capita NHS allocation of £1,900.75 compared to North Lancashire (10.1% 75+, cancer 2.05%) which only gets £1,608.94 per head. Similarly, in Yorkshire and Humber, Bradford and Airedale Teaching PCT (6.5% 75+; 1.20% cancer) has a per capita allocation of 1,645.16 per capita compared to the East Riding of Yorkshire (9.4% 75+; 2.23% cancer) with £1,440.37 per head.
What we need is less political point scoring and more of an honest debate about the tensions that arise between the principles of health care equity and health equity. In recent years, we have targeted health resources to urban deprived populations over and above levels of underlying morbidity. This appears to have been an ineffective response to health inequalities – which remain entrenched. It is one, moreover, that has exacerbated health care inequity by underestimating the health care needs of older but less deprived populations.
Competing interests: No competing interests
The Secretary of State’s (SoS) announcement(1), that allocation of NHS money to Clinical Commissioning Groups should be based on age, not poverty, is apparently intended to “test the water” for an age-only proposal for NHS resource allocation.
The argument of those putting forward this proposal is that, in more affluent parts of the country, where a higher proportion of the population are elderly , there is a greater demand for healthcare and therefore greater resources should be allocated to these areas. The fact that the crude diagnosed prevalence of diseases such as cancer is higher in more affluent areas (with older populations) than in more deprived areas, is given as evidence to support this (2).
There are two issues with this argument, firstly it is not clear that there is actually greater demand for health care in more affluent areas and secondly even if this was true, demand for health care is not the same as need and taking deprivation out of the formula, would have disastrous consequences for health equity, social justice and allocating resources where they have the greatest capacity to benefit. Leaving aside the second point for now, is there actually evidence that health care demand is greater in more affluent areas, due to their older populations?
Using the crude prevalence of people being treated for single diseases is not ideal as an indicator of demand, since it does not take into account multiple comorbidities or that there may be under diagnosis and under treatment in deprived areas. Analysis of a large national survey reveals that the crude prevalence of people reporting having any health problems lasting more than 1 year is highest in the Tyne and Wear (43%), Merseyside (44%) and South Yorkshire (45%) and lowest in Inner London (28%) outer London (35%) and the South East (38%) (Authors own analysis)(3). So even with no age adjustment the burden of ill health, on this measure, is still higher in poorer northern areas than in affluent southern areas. Health service utilization also appears to reflect this pattern. The 20% most deprived PCT populations in 2010-11 experienced 1206 bed days in hospital per 1000 population, compared to 960 in the 20% least deprived PCT populations (Authors own analysis)(4). Clearly deprivation remains an important determinant of demand and utilisation of health services, explaining regional patterns.
As health inequalities rise, and the difference in life expectancy between deprived and affluent areas of the country increase, the situation may arise that demand for health care is lower in poorer parts of the country as people die before they can take advantage of the latest medical advances that can prolong life and independence at ever greater ages. Whilst on the other hand these services are demanded at greater levels in more affluent areas, where advantage in other spheres (wealth, education and employment etc) has enabled people to live long enough to take benefit from them. The just response to this however would to be allocate resources to reduce these health inequalities, rather than to exacerbate them by taking resources away from already disadvantage populations.
1. Hawkes N. Allocation of NHS resources: are some patients more equal than others? BMJ. 2012 May 15;344(may15 3):e3362–e3362.
2. “Lansley is right to say that age trumps poverty.”[cited 2012 May 21]; Available from: http://www.hsj.co.uk/opinion/columnists/lansley-is-right-to-say-that-age...
3. Labour Force Survey [Internet]. [cited 2012 May 21]. Available from: http://www.esds.ac.uk/findingData/lfsTitles.asp
4. HESonline [Internet]. [cited 2012 May 21]. Available from: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categ...
Competing interests: BB is a Consultant in Public Health employed by NHS Blackburn with Darwen
Many areas around the country are described as being 'deprived' - it would be helpful to khow deprivation is calculated? Is the same criteria used for Scotland, Wales and England? There are some areas which seem to be described as deprived, for example Camden in N W London,when there are quite a mix of both very well off and very poor people.
Competing interests: No competing interests
Clear winners and losers under an age-only NHS resource allocation:
Hawkes is right to point out the dangerous implications for health inequalities of an age-only proposal for NHS resource allocation – there would certainly be winners and losers. Severing the link with deprivation will skew resources disproportionately towards areas with high utilisation and high concentrations of the elderly. This will lead to a considerable shift of health care funding away from the neediest, poorer areas of the North and the inner cities and towards the least needy, most affluent and most elderly areas of the South. It also means more money for Conservative voting areas and less for Labour voting areas.
Since Lansley’s April speech, I have been examining the possible impact of any ‘age-only’ allocation plan by recalculating the 2011-12 NHS resource allocation by English Strategic Health Authorities (SHA) and by Primary Care Trust (PCT). Table 1 contrasts data for the original total target resource allocation by SHA with the results of a recalculation of the original 2011-12 data with co-efficient weightings for health-need, deprivation-related need and disability free life expectancy (DFLE) removed. It demonstrates that if such an ‘age-only’ allocation approach had been taken in 2011-12 there would have been a 14.9% loss of resource in the North East region (£265 per head) and 12.0% in the North West region (£209 per head). The regional winners under such an age-only allocation are the South East Coast with an increase of 12.6% or £188 per head and the South Central area with a gain of 15.8% amounting to £220 per head.
Table 1 also presents data showing the party political composition of the electorate at the 2010 general election. This shows that the SHA areas that would have the biggest NHS resource gains under an age-only resource allocation are those in which a higher proportion voted Conservative. Those SHAs with the biggest potential losses are those where there was more support for Labour. The final columns provide employment rates and DFLE data by SHA. These show that those areas which would gain most additional NHS spending under an age-only allocation are those with the highest employment rates (an indicator of relative affluence) and better health as measured by average DFLE.
Table 2 shows the same resource allocation data by PCT. If an age-only allocation had been done in 2011-12, some Northern PCTs would have lost in excess of £600 per head (e.g. Knowsley PCT) whilst some Southern ones would have gained in excess of £350 per head (e.g. Surrey PCT).
Taken together, this data suggests that an age-only NHS resource allocation model which ignores the important link between deprivation and health, would disproportionately benefit those areas of England that are the most healthy, the most affluent and the most likely to vote Conservative: ‘Medicine is a social science, and politics nothing but medicine at a larger scale’. 
Thanks to Alison Copeland and Adetayo Kasim for advice on the data analysis.
 Department of Health. 2011-12 PCT recurrent revenue allocations exposition book. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati... [accessed 5/5/12].
 Virchow R. Der Armenarzt Medicinische Reform. 1848. 18:125–7.
Competing interests: CB is a member of the Labour Party