Allocation of NHS resources: are some patients more equal than others?

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Age is what really determines health need, the health secretary for England believes. When the new clinical commissioning groups are up and running, areas with lots of old people will no longer be penalised by the way the NHS allocates resources, he promised in a speech last month.1 This is the kind of thing you expect a Conservative minister to say, since the current formula favours young but deprived Labour voters in the cities over better-off but elderly Tories in the shires—but I was struck by the absence of reaction to Andrew Lansley’s claim. He seems to have got clean away with it.

Maybe his many opponents are simply too exhausted by the struggle over the Health and Social Care Bill to open a new front. Maybe they are adopting my default position on all NHS reform, which is that there is less in it than meets the eye. But if this policy is actually implemented it will have substantial effects across the NHS.

Its effect will be to reverse a key pledge entered into by Labour in 1999. This was that the allocation of resources should aim not to provide patients with equal access to health “care” but equal access to “health.” Resources should be directed towards areas of high health inequality to try to narrow the gaps. The fact that this policy has largely failed may, I suppose, account for the silence that greeted Lansley’s rejection of it. Even the faithful no longer put much trust in the ability of doctors to undo the consequences of lifestyle choices entered into by individuals of their own free will (or, more likely, forced on them by poverty and circumstance).

Yet the NHS Commissioning Board does not seem to be singing from the same hymn sheet. It has announced that it has identified the need for an additional director, at a salary of £200 000 (€250 000; $320 000), to focus on inequalities. And the spokeswoman for the Commissioning Board Authority (the NHS Commissioning Board in shadow form) said, in responding to Lansley’s remarks, “Our allocation decisions will be made after taking a range of views into account and supported by the best available evidence in how to secure improvements in outcomes and tackle health inequalities.”

Nobody questions the link between social deprivation and poor health. The evidence is abundant. The issue is whether this is a problem that is best tackled by directing more money at medical services in deprived areas or, as Lansley prefers, giving the earmarked money to public health.

At present, funds are allocated to primary care trusts by a complex formula that takes account of age, socioeconomic factors, health need, and the local cost of providing care. In general, socioeconomic factors trump those of age. A young population, such as that of central Manchester, scores so heavily on these “additional needs” that it is allocated more money than an older population such as that of north Dorset—more than 40% more. In most areas of England, age and poverty tend to work in opposition, since demography and social deprivation are not independent of one another: areas with older populations tend to be more affluent, those with younger populations more deprived. (I am indebted to Mervyn Stone of University College London for his step by step elucidation of the effects of each of the factors applied in the formula and to Sheena Asthana and Alex Gibson of the University of Plymouth for an elegant explanation of what it means.)

Lansley’s breezy judgment that “age is the principal determinant of health need” does not therefore reflect how resources are currently allocated. Age certainly counts for something, but other factors usually count for more.2 Included among these other factors are age standardised measures of morbidity, which do no favours to areas with large numbers of relatively healthy older people. In absolute terms their health needs are great, but age standardisation tends to obscure this.

So, Lansley can perhaps make a case for giving age demography greater importance in determining allocations. In the past, changes of allocation policy have had their sharp edges blunted by the need to keep the show on the road. Nobody expected primary care trusts to adjust instantly to a large change in funding, so they were introduced gradually over a period of years. The trusts were told how far away they were from “target,” with the aim of gradually narrowing the gap.

However, we now face a different situation in which the NHS Commissioning Board will have the responsibility of allocating budgets to entirely new organisations—the clinical commissioning groups—which will not be coterminous with the old primary care trusts. There is therefore an opportunity to make a more abrupt change, should Lansley’s prescription be followed.

His aim, as he explained it to a clinical commissioners’ conference, was for resource allocation to ensure that patients everywhere had “equivalent access to NHS services” and for public health funding to take account of indices of deprivation. The Health and Social Care Act spells it out: the duties of clinical commissioning groups in reducing inequalities are restricted to reducing inequalities between patients “with respect to their ability to access health services” and “with respect to the outcomes achieved for them by the provision of health services.” Similar duties are laid on the NHS Commissioning Board. They must provide equal access, and equal outcomes, as near as they can: reduce unacceptable variation, in other words.

One could argue that to achieve equivalent outcomes, deprived areas need more resources. But that is not what Lansley is saying. We haven’t heard the last of this particular argument.