Clear winners and losers are created by age only NHS resource allocationBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3593 (Published 22 May 2012) Cite this as: BMJ 2012;344:e3593
All rapid responses
The continuing divide in health status illustrates the need for a fair funding formula for the NHS. Life expectancy at birth has been used as a measure of the health status of the population of England and Wales since the 1840s. Recently published statistics from the UK Office for National Statistics show that the North-South divide in distribution of life expectancy across England continues, with people in local areas in the North generally living shorter lives than those living in the south.
The figure shows life expectancy (LE) for males at birth by local authority district in England and Wales during the period 2010–12. Male life expectancy at birth was highest in East Dorset (82.9 years) and lowest in Blackpool (74.0 years). For females, life expectancy at birth was highest in Purbeck at 86.6 years and lowest in Manchester at 79.5 years. Life expectancy at birth increased across England and Wales by 1.3 years for males and 1.0 year for females between 2006–08 and 2010–12.
Life expectancy at age 65 was highest for men in Harrow, who were expected to live for an additional 20.9 years on average compared with 15.8 years for men in Manchester. For women at age 65, life expectancy was highest in Camden (23.8 years) and lowest in Blaenau Gwent (18.7 years). In 2010–12, approximately 28% of local areas in the East, 49% in the South East and 28% in the South West were in the 20% of areas with the highest male life expectancy at birth. In contrast, there was no local area in the North East and Wales in this group. A similar pattern was observed for females.
A number of factors underlie the North- South divide in life expectancy, most importantly, socio-economic factors such as deprivation and lifestyle factors such as smoking and diet. A funding formula for the NHS that targets resources at areas with poor health status is an essential component of strategies to tackle these on-going health inequalities.
1. Office for National Statistics. Life expectancy at birth and at age 65 for local areas in England and Wales, 2010-12. Newport, Wales, 2013.
2. Majeed FA, Chaturvedi N, Reading R, Ben-Shlomo Y. Monitoring and promoting equity in primary and secondary care. BMJ. 1994;308:1426–1429.
Competing interests: No competing interests
A recent report by Public Health England showed that between 2009 and 2011 people in the North East and North West were more than twice as likely to die early (e.g. Manchester has 455 deaths per 100,000) than people living in the South East (e.g. Wokingham has 200 deaths per 100,000) . Northern areas also have higher rates of premature deaths from cancer, respiratory diseases and circulatory diseases; lower life expectancies; and higher prevalence of limiting long-term illness . NHS need and usage is subsequently higher in the North with, for example, 29 out of the 30 Clinical Commissioning Groups (CCGs) with the highest emergency admission rates for conditions usually managed in primary care located in the North of England . Much of this geographical inequality in health is related to higher levels of deprivation in the North .
NHS funding is allocated to areas on the basis of providing “equal opportunity of access for equal need”  so that areas with higher health need should have a higher per capita level of NHS funding. The allocation formula currently in use incorporates a deprivation-related measure to account for the additional needs of income-deprived populations – the Health Inequality Weighting (which uses area-level Disability Free Life Expectancy rates) . This has helped to ensure higher budgets for Northern and urban areas, such as London, where deprivation is highest. The relative role of deprivation compared to age as determinants of health need has been subject to political debate over the last year  and the Advisory Committee on Resource Allocation (ACRA) subsequently proposed a new formula in December 2012  – the Weighted Capitation Formula for Clinical Commissioning Groups . This formula removes the Health Inequalities weighting and thereby increases the weight given to population age . Concerns were expressed that the new formula would lead to significant geographical shifts in NHS budgets from “from areas where people sadly have worse health outcomes to those where people have much better outcomes” . This has resulted in an NHS England led ‘Fundamental Review of Allocations Policy’ and a consultation on the proposed changes to the formula .
Using the data provided by NHS England in the consultation , we have mapped the difference in funding per person between the current ‘Health Inequalities’ formula and the new ‘Capitation’ formula for each of the English CCGs (Figure 1) and NHS Area Teams (Figure 2). This very clearly shows that it is predominantly CCGs in the affluent South of England (particularly the South East) that will benefit from the new formula, whilst those in the poorer North East and North West (and some in the Western periphery) will lose out substantially. For example, in CCGs like South Eastern Hampshire, where average life expectancy is 81 years for men and 84 years for women and healthy life expectancy is 67 years for men and 68 years for women, NHS funding will increase by £164 per person (+14%). This is at the expense of CCGs such as Sunderland, where average life expectancy is 77 years for men and 81 years for women and healthy life expectancy is 57 years for men and 58 years for women, and where NHS funding will decrease by £146 per person (-11%) . More deprived parts of London will also lose out with Camden CCG receiving £273 less per head (-27%) under the proposed formula.
Whilst these changes are not on the scale that a purely ‘age-only’ allocation formula would produce (as modelled previously in ), it is our assertion that they are still sufficient to undermine the NHS funding principle of “equal opportunity of access for equal need” as areas with healthier populations will receive more funding whilst those will less healthy populations will receive less. It also needs to be noted that many of these are the same localities that have also lost out from above average cuts to Local Authority budgets . The scale of the potential NHS funding shifts will add further stress onto these local health and social care systems and potentially widen the North-South health divide by reducing access to NHS services in the North. The new capitation formula is out for consultation and we urge concerned BMJ readers to respond .
 Public Health England (2013) Longer Lives http://longerlives.phe.org.uk/ [accessed 7/10/13]
 Health and Social Care Information Centre (2013) Indicator Portal. http://www.hscic.gov.uk/ [accessed 7/10/13]
 Whitehead, M., Doran, T., 2011. The north-south health divide. BMJ 342, d584–d584.
 NHS England, S.F., 2013. Annex C - Fundamental Review of Allocations Policy: Technical Guide.
 Williams, D. (2012) Lansley: CCG allocations should be based on age, not poverty Health Service Journal [26th April 2012]
 Bambra, C. (2012) Clear winners and losers with an age-only NHS allocation. British Medical Journal, 344:e3593. doi: 10.1136/bmj.e3593.
 Dowler, C. (2012) Commissioning board's funding formula move was not 'political', Health Service Journal [18th Dec 2012]
 NHS England (2013) Fundamental Review of Allocations Policy http://www.england.nhs.uk/2013/08/15/rev-all-wrkshp/
 Office of National Statistics (2013) Animated map of healthy life expectancy in England http://www.ons.gov.uk/ons/interactive/healthy-life-expectancy-at-birth-f...
 West, D., 2013. Areas with worse life quality would be hit by allocation shake-up. http://www.hsj.co.uk/news/finance/areas-with-worse-life-quality-would-be... [accessed 7/10/13]
Competing interests: No competing interests
Professor Bambra’s analysis of the impact of age-only resource allocation written in response to Hawkes’s concerns  about the validity of the funding formula is pertinent but it fails to address the underlying assumption that demand for healthcare will be proportionate to need.
The inverse care law is well recognised as Tudor Hart has explained; underuse of healthcare by deprived people is a “great enemy” It can be seen in the differential access to care for patients with bowel cancer according to site; patients resident in a deprived locality with colonic cancer are less likely to gain access to treatment than those with rectal cancer. Perhaps this can be explained in terms of competition between patients; the patient with rectal bleeding is more competitive in the allocation of diagnostic resources than is the one with vaguer symptoms especially if the individuals concerned do not argue their case articulately. We must learn to interpret the NHS as a competition between patients for resources.
The consequence of this is that the resources allocated to deprived areas should not be reduced but it should be made easier for people from disadvantaged backgrounds to make use of them. Resources for more affluent areas should be increased to meet the fully-recognised needs of the articulate competitors and also to allow their less competitive deprived neighbours to have access to services.
 Bambra CL Clear winners and losers from age-only resource allocation. BMJ 2012; 344:e3593
 Hawkes N Allocation of NHS resources: are some patients more equal than others? BMJ 2012;344:e3362
 Tudor Hart JT Commentary: three decades of the inverse care law BMJ 2000;320:18-9.
 Crawford SM, Sauerzapf V, Haynes R. Social and geographical factors affecting access to treatment of colorectal cancer: cancer registry study. BMJ Open 2012;2:e000410. doi:10.1136/bmjopen-2011-000410
 CRAWFORD SM Personal View Competition is intrinsically wasteful. BMJ 2012;344:e3199
Competing interests: No competing interests