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Lansley: CCG allocations should be based on age, not poverty

Health secretary Andrew Lansley has suggested clinical commissioning group funding should take into account the age of a population rather than indices of deprivation, arguing age is the “principal determinant of health need” in an area.

From next year CCG budgets will be decided by the NHS Commissioning Board with guidance from the Advisory Committee on Resource Allocation.

Mr Lansley told the NHS Clinical Commissioners conference in London on Tuesday: “Age is the principal determinant of health need.

“What should happen – the advisory committee will do this, I won’t – the number crunching should get progressively to a greater focus on what are the actual determinants of health need.”

Answering a question from a CCG leader about whether areas without high levels of deprivation would be “penalised” by lower funding settlements, Mr Lansley said “wherever you are in the country you should broadly have resources equivalent with access to NHS services.”

Mr Lansley said: “They should be looking at what it is in your population data that is likely to give rise to a demand for NHS services - the respective burden of disease.

“What is likely to make the biggest difference, therefore? Actually it’s elderly populations who were not in substantial deprivation.”

He said some of the lowest spending on stroke and cancer services were in areas with high elderly populations such as Fylde and Eastbourne, “places where there were quite a lot of older people who weren’t poor”.

The secretary of state said council funding for public health would be based on indices of deprivation, but this would come with a “direct expectation” that the money would be spent on tackling poverty-related health need.

Mr Lansley also encouraged CCG leaders to be innovative in their approach to the tariff.

“The tariff is made for man, not man for the tariff”, he said. “If the tariff serves your purposes use it. If it doesn’t, create a different community tariff or an unbundled tariff”.

Mr Lansley said the debate around the Health Act had caused a “big burst of politics – not just party politics but politics in the health service”. However, “part of objective was to get beyond that for good”, to make the service more autonomous and directly accountable.

But Mr Lansley said the “mechanics of change” over the next six months would be more difficult than “any subsequent time” as the new NHS structures were created.

“A lot of people will be trying to live in two worlds at the same moment,” he said. “Try to do the day job while they’re trying to do the shaping of the future.”

Readers' comments (30)

  • Richard Russell

    Many people have heard me say that PbR is far from perfect but it is a lot better than the block contract approach we used to have - principally because it makes everyone focus on the pathways a patient is on, especially where it is high cost.

    As such I welcome the comment “If the tariff serves your purposes use it. If it doesn’t, create a different community tariff or an unbundled tariff” - I always see PbR as a useful level/facilitator and there is loads that can be done with it.

    Having worked with PbR for almost 9 years I have never found a situation where PbR prevents a solution being put in place and usually, albeit sometimes with some creative thinking, it puts the financial levers in place to help new solutions be implemented.

    So not perfect but definitely usable...

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  • In the Parliamentary debate on the health inequalty "spearhead" areas in 2004, Lansley accused the Government of moving money to Labour constituencies. This sounds like a pretty brazen way of trying to move a lot more of it back to Tory voting constituencies.

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  • Maybe AL should be aware of the findings of the Black Report on health inequalities, and all the myriad of more recent data and reports underlining social deprivation as the key determinent of health need.
    Let's hope the Advisory Committee on Resource Allocation are rather better informed, and take expert public health advice.

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  • As ever - what does the peer-reviewed academic evidence say?

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  • Most health care is needed in the first 18months of life and the last 5 years. The money should be focussed accordingly.
    Allocating monies on the basis of deprivation has never produce any noticeable changes nor reductions in health inequalities. Living in the centre of a town is always going to be less healthy than living in the countryside. If only because you are in contact with more potentally unhealthy people. Hence the inequalities will alwasy be there

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  • @Anon 14:46

    I'd be curious to see the data you base your statements on.

    Whilst it is well-established that most healthcare resources are *consumed* in the first 18 months and last 5 years of life, this is not necessarily an indicator that these resources are *needed*. I've seen good arguments made that ageing and death are currently associated with a considerable degree of un-needed interventions.

    Allocating funds to deprived areas has a long history of noticable changes on health status - the investment in proper sewer systems for deprived urban areas in the 19th Century comes immediately to mind.

    Your proposed urban/rural dichotomy does not agree with available data; for example, the recent Index of Multiple Deprivations shows that Fernhill in the New Forest has a much higher level of health deprivation than the City of London.

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  • Ooop north in our poor inner city area a lot of our people don't live long enough to reach old age

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  • If, as mentioned by 2.46 pm, the majority of healthcare spending is spent on the first two years and the last five years of life, then irrespective of how many years people live between these milestones, they will need relatively little healthcare in between. Therefore there is no need to take longevity into account, and AL is indeed ill-informed, as Anon 1.38 pm pointed out.

    Based on the figures from Anon 2.46 p.m, every person surviving more than 7 years (i.e. 2 early yrs + 5 last yrs) uses roughly the same funding during their lifetime, which suggests a per capita approach to healthcare funding -- which is neither AL's nor the Black Report's view.
    Surely the weight of PH evidence gained over many years in every corner of the globe needs to be heard and adopted here in the UK.

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  • Play down deprivation?
    Study after study under labour and conservative governments have shown it is a critical determinant (as also is demography).
    In my CCG the men in the more affluent part live for 14 years more than those in the deprived part.

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  • If you search the ACRA pages of the DoH website, it's quite illuminating. Cassandra, this is the key letter referred to:
    http://tinyurl.com/cukgh52
    and the bit on inequalities states that whilst they can see investment is necessary, they can't quantify it so left it the same for 11/12 but AAAAAAH "the scale of the adjustment is a matter for the SoS judgement" (based on the disability free life expectancy formula)
    All in all though, very useful reading. We will be challenged on this by CCGs so I'm certainly going to make sure I understand at least the key points....

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  • I confess an interest but if age is a key factor in determining allocation let's hope that there is some realisation that children and young people are as needy as old ones.

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  • David Hooper

    But in the London Borough of Enfield there is nearly a ten year difference in life expectancy between the most and least deprived wards in the borough. The last seven years of life begins several years earlier for those in deprived areas!

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  • he's a dimwit. and there is an ever growing published evidence base to support this view.

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  • This is a fascinating and complex topic, and Andrew Lansley has, yet again, revealed ignorance and prejudice. It certainly looks like his proposals would move funds towards richer (Tory) parts of the country, and he must know that. The real question is: what are we trying to achieve through healthcare expenditure? If we want equality, then presumably we want to arrive at roughly the same average lifespan everywhere, in which case areas with lots of older people should get less not more funding. If we want to maximise overall health gain, extending the last years of life may not be the best solution. Simply giving more funds to areas with more old people will tend to increase inequality between rich and poor areas; and, in the macro economy, it seems an odd priority when we can hardly afford pensions based on present lifespans.

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  • I am struggling with this concept. Surely age alone is too narrow a perspective.

    This needs to be split down to healthy years and unhealthy years. There's no point giving more money to a 90 year old in good health, over a 60 year old in poor health.

    I would have thought the more deprived the area, the lower the average life span, the money you would need?

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  • As a CCG Clinical Chair I feel totally let down by Andrew Lansley's comments.The patients in my geography die 10 years younger due to CHD than the neighbouring more affluent areas and all the public data points to depivation, obesity and smoking as being the underlying causes .As a CCG lead I finally thought we could make a difference in this, but not if funds will be going to other areas just because they have older patients .This will just perpetuate the "inverse care law" and increase the inequality I see .

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  • Is there any good reason to believe this is not being done for party political purposes?

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  • Although politically unpallatable, there is an argument to say that the first years should be funded by individuals not the state. Or at least in respect of maternity care there is often nothing wrong with you but you need medical help to assist in the pregnancy/delivery. From a logical point of view you should save up for your baby because it is a planned event, thus freeing up resources to cover unplanned events and ailments/diseases that blind-side you and over which you have no control. However I accept that this will never happen in the real world as it is too far part of societal norms now. But food for thought.

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  • Going back to the point about the tarriff. Is this an indication that competition on price is back on, as surely if you do not use tarriff you are starting down the route of value (as defined by Porter as Outcome/cost) being determined not by maximising outcome but rather by decreasing price. Only asking, I am sure he did not mean that.

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  • I'm no expert but if

    "some of the lowest spending on stroke and cancer services were in areas with high elderly populations such as Fylde and Eastbourne, “places where there were quite a lot of older people who weren’t poor”."

    then this suggests poverty not age leads to high costs. Isn't this the opposite of the point he's trying to make?

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